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Full text of "On fractures and dislocations"


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HARVARD MEDICAL 
LIBRARY 




RÖNTGEN 

THE LLOYD E. HAWES 

COLLECTION IN THE 

HISTORY OF RADIOLOGY 





THE NEW SYDENHAM 

SOCIETY. 



INSTITUTED MDCOOLVIII. 



VOLUME CLXVII. 



ON 



FRACTURES AND DISLOCATIONS 



PROFESSOR DE. H. HELFERIOH, 

OF ÖEIEF3WA1D. 



ILLUSTRATED WITH 68 PLATES AND 126 FIGURES IN THE TEXT, 
DRAWN BY B. KEILITZ. 



TRANSLATED FROM THE THIRD EDITION (1897) WITH NOTES 
AND ADDITIONAL ILLUSTRATIONS 

BY 

J. HUTCHINSON, JuN., F.R.C.S., 

SUKGEON TO THK LONDON HOSPITAL. 



LONDON: 
THE NEW SYDENHAM SOCIETY. 

1899. 



Digitized by tine Internet Archive 

in 2011 with funding from 

Open Knowledge Commons and Harvard Medical School 



http://www.archive.org/details/onfracturesdisloOOhelf 



TRANSLATOR'S NOTE. 



The work has been divided into chapters, and 
an index added ; several additional illustrations are 
also inserted. The notes to the text are in all 
cases by the translator. 

J. H., JUN. 



ON FUACTUliES AND DISLOCATIONS. 



CHAPTER I. 

GÜNEIUI. CONSIDERATIONS ON FßAGTUßES. 

In speaking of fractures we have first of all to distinguish 
between those produced by external vi"lence (traumatic 
fractures), and those which arise either without any external 
injury^ or from such slight force as would not suffice to break 
normal bones (spontaneous fractures) . Spontaneous fractures 
are the result of a fragility which as a rule is caused by 
tumours (sarcoma^ metastatic carcinoma^ hydatid cysts^ &c.), 
or by inflammatory disease of the bones (osteomyelitic 
necrosis^ abscess^ tubercular caries, syphilis, rickets, osteo- 
malacia, &c.).^ 

The consideration of spontaneous fractures will be omitted 
from the following work, which treats only of traumatic 
fractures of healthy bones. These we may divide into com- 
plicated and uncomplicated fractures (/. e. simple or subcu- 
taneous ones), the complication consisting in a simultaneous 
wound of the skin and soft parts near the point of fracture. 
As a rule the fracture is thus itself exposed to the air, and 
the danger arises from infection from without ; but a smaller 

^ Fractures of long bones from slight causes may occur in the subjects of 
tabes dorsalis and paraplegia, and may fairly be attributed to atrophy and 
rarefaction of the bones, due to the lesion of the nervous system. In tabes 
dorsalis fractures may occur before the onset of Avell-marhed ataxia. Tliey 
are most common towards tlie joint ends of the bones, are repaired with 
great difficulty, and if union does result it is attended with the formation 
of excessive callus (see Charcot's works, New Syd. Soc. Trans., and papers by 
Eivington and Hulke in 'Med.-Chir. Trans.,' 1893, pp. 171 — 196). — J. H. 

1 



2 OU AFTER 1. 

wound of skin and soft parts^ not reacliing directly to tlie 
point of fracture^ is in the same sense a complication. In 
these cases the antiseptic or aseptic treatment of wounds^ 
according to the prevalent rules of surgery^ is to be rigorously 
carried out, for then only can we count upon a good result 
in these cases 6f compound fracture which were formerly so 
dangerous. Apart from these precautions the treatment of 
these fractures is naturally based on the same principles as 
that of the subcutaneous ones, with the object of obtaining 
firm union of the broken bone with the least possible dis- 
placement or deformity. Experience shows that this task 
is much harder in cases of complicated fracture, and that 
sometimes we have to be content with a result which is far 
from perfect. 

According to the degree of separation of the fragments 
at the point of fracture, we speak of a complete and of an 
incomplete form. To the latter belong the fissure fradAire, 
which traverses the bone without altering its external form, 
and the green stich fracture, which is most commonly seen in 
the bent tibiae of rickety children, although it is also 
observed in other long bones of young adults, and in some 
of the flat ones.^ In complete fractures the line of cleavage 
may have a varying direction, and we distinguish between 
transverse, oblique, longitudinal, and spiral fractures ; if 
small fragments of bone are completely detached at the 
point of fracture, with or without their periosteal covering, 
we speak of a splintered fracture. 

We may have also a multiple fracture of one and the' same 
bone (at its upper and lower ends, and its middle), and 
finally simultaneous fractures of several bones (for instance, 
of the parallel bones of forearm and leg), or of bones widely 
separated from each other. It is of some interest to decide 
whether a fracture has occurred from direct or from indirect 
violence, — for instance, if the ulna is broken in parrying a 
severe blow we have a direct fracture ; if a child falls on its 
hand and sustains a fracture of the clavicle or the lower end 
of the humerus the fracture is indirect. Since in the former 

' As, for instance, in the remarkable depressions of the cranial vault 
sometimes met with in young children, which are almost invariably ob- 
literated in time. 



Tab. 1. 





Fa^Icl B^i^ %^^ ^^-^ 



Li(,li.Äiisl,.v. K, Reinlihold , Müiiclini 



PLATE I. 

GREENSTICK FRACTURES. 

Figs. I a, h. — Tibia and fibula of the left lower limb of a boy aged 
fourteen, wbo was caught between the cog-wheels of a threshing 
machine. The fibula is fractured about three fingers' breadth higher 
than the tibia ; both bones are so bent at the point of fracture as to 
form a prominent angle forwards, a concavity backwards. The bend- 
ing has brought about, in the first place, a gap on the convex side, 
and then produced a typical wedge of bone which is nearly detached 
so as to make a complete fracture ; but it will be seen that the wedge 
is not wholly detached, at its lower end in the case of the tibia, at its 
upper in the case of the fibula. 

Figs. 2 a, b. — Tibia and fibula from the body of a young adult in 
whom, by means of an osteoclast, a fracture was experimentally pro- 
duced. It will be seen at once that the fracture is a greenstick one. 
In the case of the tibia it is a beautiful example of an oblique frac- 
ture. 



GKNERAL CONSIDERATIONS ON FEAOTUBES. 3 

contusion and litemorrliage are present at the site of fracture^ 
so the direct forni^ as a rule^ must be held to be a more severe 
lesion than the indirect. 

A point of interest to remember is the prevalence of 
different kinds of fracture at different ages. That the 
middle period of adult life furnishes the largest proportion 
of fractures is easily understood^ since these patients are 
mostly engaged in hard work, and subject to accident. 

In order to calculate this proportion correctly we have to 
consider the exact numbers of the population at different 
ages. We then find that fractures are most numerous 
between the ages of thirty and forty years (i5"4 per cent.) ; 
further^ in old people fractures are more numerous than in 
children ; amongst the latter the minimum frequency is during 
the first ten years. The reason why fractures are so frequent 
in old age is partly the greater fragility of bone due to the 
senile atrophy^ or diminution of the organic constituents. 

In early life the presence of the layer of cartilage between 
the diaphysis and the epiphysis plays an important part^ and 
we then meet with not so much true fracture as a traumatic 
separation of the epiphysis (as may occur spontaneously from 
inflammatory processes^ particularly from acute osteomyelitis 
and from inherited syphilis). 

In discussing the mechanism of the production of fractures 
we shall have to base our deductions upon the study alike 
of preparations obtained by accident^ and of those derived 
from experiments on the dead subject. Most forms of 
fracture can be artificially produced without difficulty ; and 
with the aid of this experimental evidence and by careful 
study of specimens of fracture^ the shape of the fragments^ 
■ &c., one can often deduce the kind of violence that has led 
to itj a point that may be of importance in forensic medicine. 
For example^ greenstick fracture (see Plate I) is produced by 
bending a bone beyond the limit of its elasticity. The long 
hollow bones are thus broken in exactly the same way as a 
stick is bent and broken over one's knee. In actual life this 
fracture may arise in several ways, — for instance, by the 
passage of a weight over a bone having a hollow beneath 
it, by a violent strain on a bone which is fixed at one end, 
and by pressure in the longitudinal direction on a bone which 



CHAPTER I. 



bends it, and if continued breaks it at its weakest and most 
curved point. 

A greenstick fracture can also be produced by means of 
the osteoclast, or by simply bending a weak bone over the 
edge of the table. 






Fig. I. — Different forms of characteristic greenstick fracture. 

a. Oblique fracture. 

b. Transverse fracture with fissures. 

c. Oblique fracture with detachment of a wedge-shaped 

piece. 

The form of a greenstick fracture is very characteristic and 
easily recognised in specimens, a fact which may be of im- 
portance from a medico-legal point of view. On the convex 
side of the curve there is a fissure, which as a rule is trans- 
formed into a slight gap by the pressure of a wedge of bone. 
The base of this wedge, which may or may not be wholly 
detached from the rest of the bone, is invariably placed on 
the concave side of the bent bone. 

It is obvious, therefore, that by strong bending or inflec- 
tion we have produced either a fissure or a true fracture 
(with detachment of a piece of bone), and that the fracture 
may be either transverse or oblique, according to the form 
or direction of the wedge. 

It is possible perhaps to distinguish a variety of fracture 
from cracking or squeezing a long bone, which is produced 
by direct lateral pressure on the end of a bone which is fixed 
above, although no great bending occurs at the point where 
it gives way, e. g. the typical Pott's fracture of the fibula, from 
pressure everted through the astragalus. 

The torsion fracture (Plate II) is always caused by a 





Elg.lcL 



Ei^Jh 






tig.^b 



LülvAnsi v. y, RsichhoW , Munchm . 



PLATE II. 

TORSION FRACTURES. 

Figs. I a, b. — Torsion fracture of the upper half of the shaft of the 
femur from a woman aged eighty. The fracture arose from a twist of 
the body when her foot was fixed. The left femur is shown in its 
front aspect, and a beautiful spiral fracture displayed. 

In fig. I b the two fragments are shown side by side (so to speak, 
unfolded from each other), so that the spiral form, the very oblique 
line of fracture, and a longitudinal split in the upper fragment may be 
observed. 

Figs. 2 a, b. — Ai'tificially produced torsion fracture. The spiral line 
can be well seen, and in fig. 2 & a rhombic fragment has been lifted 
aside. Two fissures running up the shaft are also shown. 



Tab. 3. 




Figlci 



Fig.lh 





Ei^.3 



Liihinsi V, Fllcjohhold , Müiiiiim 



PLATE III. 

FORMS OF PBACTUEE PRODTJCED BY COMPRESSION, TEARING, OB 

CRUSHING. 

Figs. I fl, b. — Impacted fracture of the upper end of the tibia. 

In fig. I a the front aspect is represented, and in fig. i b the vertical 
section of the bone. Both drawings explain themselves, and show 
especially what extreme pressure must have been exerted through the 
condyles of the femur on to the upper surface of the tibia, the shaft of 
which is driven into the separated fragments of the cancellous joint 
end. 

Fig. 2. — A perfect example of the fracture from tearing, showing the 
lower end of the forearm of a young adult. ^ Both styloid processes 
are bi-oken off in a jagged line. The detachment was produced by a 
machine accident to the hand, a violent dragging force being exerted 
through the lateral ligaments. The detachment of the styloid process 
of the ulna was incomplete. 

^i§'- 3- — Fracture from crushing the wrist end of the radius by 
machinery. The patient, a man aged fifty, slipped whilst attending 
to a steam engine, and had his left arm caught between the cylinders. 
Owing to the injury to the soft parts a primary amputation was 
required. 

^ It is unfortunate there is no word in English which conveys the 
meaning of the German " Rissfraktur." It clearly expresses what may 
occur when a violent strain is produced on a particular part of a hone 
through the ligaments attached to it, and when the bone gives way rather 
than the ligament. Examples of it are numerous, e.g. fracture of the 
internal malleolus from forced aversion of the foot ; fracture of the styloid 
process of the ulna with Colles's fracture of the radius ; and fracture of the 
internal epicondyle of the humerus complicating dislocation of the elbow. 
In all these cases the fragment of bone is torn or dragged off by the force 
exerted through the attached lisrament. — J. H. 



GENERAL CONSIDERATIONS ON FRACTURES. 5 

twisting or rotatory force, and may arise when either ex- 
tremity of the long bone is fixed. As a rule it is the end of 
the limb that is fixed, and the twisting force is exerted 
through the body, e. g. in a fall forwards when the foot and 
leg are fixed. On the dead subject a spiral fracture can be 
produced when the body is fixed and the limb violently 
twisted, especially if at the same time a sharp blow with a 
hammer is given over the part to be fractured. As a rule 
the bone breaks in a well-marked spiral line, and if the force 
is sufficient this spiral passes completely round the bone. 
Frequently two vertical lines of fracture join this spiral line, 
and in this way a rhombic fragment is more or less com- 
pletely detached ; its formation is characteristic of torsion 
fracture. Although the torsion fractures are always pro- 
duced by indirect violence, yet they are of unfavourable 
prognosis, since the sharp fragments are apt to be displaced, 
to cause haemorrhage, or even to perforate the skin. 

Fractures from compression or squeezing (Plate III) are 
caused by external violence, which produces a sudden com- 
pression of a bone. This usually happens from the force 
being transmitted through a bone of greater resistance. 

If the pressure is exerted through the shaft of a long bone 
the characteristic impacted fracture is produced at its joint 
end, in which the compact diaphysis is driven into the wider 
and more spongy region of the epiphysis. For examples of 
such compression fractures see Plate XXXIII, fig. 3 (upper 
end of the humerus), Plate LIY (impacted fracture of neck 
of femur into the great trochanter), Plate III, figs, i a and 
I h, Plate LXIII, figs. 3 a and 3 h (upper end of tibia and 
fractures of the os calcis from a fall on the foot). 

To this category belongs also the detachment by pressure 
of small pieces of the articular borders of the bones. 

Fracture from traction or dragging force is caused by a 
sudden pull exerted through muscles or ligaments, more 
rarely through an external force {e. g. the belt or strap of 
some machinery), at the same time that the neighbouring 
joint is forcibly bent or twisted. 

Characteristic examples are found in the case of the 
patella and olecranon, fractures of the ankle, of the lower 
end of the radius, &c. 



Ö CHAPTEE 1. 

Fractures from crushing are illustrated in Plate III, fig. 
3. In sucli a case a heavyweight may completely crush the 
bone into a number of irregular fragments (Plate IV). In 
fractures due to projectiles it may be noted that if a gun 
laden with shot is fired close to a limb the effect will be 
similar as regards splintering of the bone to that caused by a 
bullet. The modern weapons of warfare produce great 
splintering at distances, for instance, of less than half a mile. 
This effect in the war of 1870 led to the suspicion that the 
French used explosive bullets. The excessive splintering is 
explained either by the theory of hydrostatic pressure work- 
ing through the bone, or more probably by the sudden and 
forcible displacement of small fragments of bone which 
exert their effect far beyond the part impinged upon. At 
very long distances, e. g. a mile, bullets produce circular 
apertures. 



The Symptoms op a Kecent Feactuee. 

The most characteristic feature of a fracture lies in the 
solution of continuity of the bone affected. i. Abnormal 
mobility is the most important symptom, which, however, is 
wanting in the incomplete fractures and the fissured and 
impacted ones. For instance, the narrow shaft of a bone is 
driven into the expanded cancellous end, and so fixed that 
the two fragments again form a complete whole. In some 
other cases, such as fracture of the short bones and of the 
ribs, abnormal mobility is not always to be detected. 

2. The presence or absence of crepitus depends chiefly on 
the existence of abnormal mobility. Other causes may lead 
to the absence of crepitus in fracture, as, for example, when 
the fractured ends are so displaced that they cannot be 
rubbed against each other, or when soft parts, such as por- 
tions of muscle or fascia, are interposed. 

3. Another very important symptom of fracture is the 
visible or palpable deformity, which again is absent in fis- 
sured fractures and certain complete fractures in which 
there is no displacement. It is unnecessary to dwell on the 
importance of carefully comparing the bone of the oppo- 



Tab. 4. 





Fig. 3b 



Eig.3a^ 



FigJ 



litti.Änsi .V. F. Rpirlihnld , MüihIhii 



PLATE lY. 

GUNSHOT FRACTURES. 

These fractures were experimentally produced by means of tlie 
modern German army rifle, loaded with the full amount of powder, 
and a bullet of 8 mm. diameter. 

Fig. I. — Fracture of the femur caused by bullet fired from a distance 
of 600 metres. The splintering is seen to be extravagant. The frag- 
ments have been put together again. 

Fig. 2. — Fracture of the tibia produced by bullet fired from a dis- 
tance of 50 metres. The central hole and the radiating lines of frac- 
ture are well seen. 

Fig. 3. — Bullet aperture caused by rifle fired at the distance of 1500 
metres. Soft parts, periosteum, and bone in the fresh state were 
cleanly bored through. Some fine fissures are shown. The aperture 
of exit at the back of the humerus was somewhat smaller than that of 
entrance, but was, like it, of circular form. 



Tab. 5. 





Fu).1 



Fig.. 



Litli.Anstx F RiMoliliold. Miiiirli.'ii 



PLATE Y. 

DISPLACEMENT OF FRAGMENTS. 

Figs. I and 2 ave from the same preparation of an ununited fracture 
of tLe femur, and show axial rotation, overlapping and lateral dis- 
placement. 



GENEBAL CONSIDERATIONS ON ERACTUBES. « 

site side, and noting wliethei' oi' not there is shortening. 
Various forms of displacement have been described, as 
follows : — lateral, angular, longitudinal, &c. 



n 



iP^f^ 



1J 






=1. 



d 



Fig. 2. — Diagrammatic representation of tiie various forms of 
displacement. 

a. Lateral. 

b. Axial. 

c. Overlapping of fragments. 

d. Vertical separation. 

e. Axial rotation. 

The causes of the deformity are of three kinds : — ist, the 
displacing force at the time of accident ; 2nd, muscular con- 
traction ; and 3rd, the weight of the limb. 

4. Effusion of blood in the adjoining soft parts is usually 
greatest in the case of direct fracture. Here, the crushing 
force and the fracture itself both help in producing it ; if 
the fracture is close to a joint there is hgemarthrosis. The 
effusion of blood, if considerable, may render difficult the 
correct diagnosis of the fracture. 

5. Pain in cases of fracture loses somewhat of its signifi- 
cance as a symptom from being purely subjective. In con- 
trasting this pain with that attending a simple contusion, it 
is to be noted that the pain in fracture will be most intense 
at one localised spot, and much more widely felt in the case 
of a contusion. Jn fact, this symptom is of value only in 
indirect fractures, where the force has been applied at some 
distance from the point of fracture. At the same time, with 
impaction and fracture of bony prominences at the joint- 
ends, marked pain during certain movements of the joint, or 
during the contraction of muscles attached to them, may be 
a symptom of value. 

6. Disturbance of function varies naturally with the kind 
and site of fracture ; thus, for instance, it mav be very slight 



8 CHAPTER I. 

in some cases. Patients with recent impacted fracture of 
tlie neck of tlie femur, or fracture of the fibula alone, may- 
be able to walk, and patients with recent fracture of the 
ulna may be able to use the arm. 



The Examination of Oases op Fracture. 

I strongly recommend the more frequent use of anaes- 
thetics in suspected cases of fracture, for without their aid it 
is often impossible to make a correct diagnosis. Particularly 
difficult and responsible is the examination of patients who 
are unconscious after an accident ; here it must especially be 
remembered that many fractures or that both fractures and 
dislocations maybe present at the same time.' . The import- 
ance of exact measurements and comparison with the sound 
side must also be emphasised. In the examination of cases 
where the fracture has occurred at some distance of time, 
and the reason for or degree of incapacity for work has to 
be estimated, the greatest care must be taken in coming to 
a conclusion. As a rule some deformity will be found as 
the cause of persistent loss of function, but we have also to 
think of troublesome oedema, excessive formation of callus, 
persistent mobility (delayed union), stiffness of the adjacent 
joint, injury to a neighbouring nerve-trunk, atrophy of the 

• For example, a man fractured one forearm in a fall. This was well 
treated, but the fact that he had dislocated the humerus on the same side 
was overlooked for six weeks. At the end of this time, after several 
attempts, the bone was reduced, but an axillary aneurism followed, which 
was successfully treated by ligature of the subclavian artery (Rushton 
Parker, 'Lancet,' April i8th, 1885). 

A young man sustained a compound fracture of the skull which necessi- 
tated trephining. Whilst in the liospital his temperature continued to be 
raised, and a swelling formed over the left clavicle. This proved to be an 
abscess which had developed around a simple fracture of the clavicle, which 
had been overlooked for a fortnight chiefly on account of the gravity of his 
head injury. 

A man sustained a compound fracture of his right elbow. He was 
treated with success for this in hospital, but complained persistently of 
pain down the arm. At the end of a month this was discovered to be due 
to a dislocation (subcoracoid) in the shoulder above, which was fortunately 
reduced. — J. H. 



Tab. 6. 



Fig. 1. 



Fig. 2. 



PLATE VI. 

Fig. I. — Fracture of tbe left humerus. Skiagraph taken from the 
back. 

Fig. 2. — Skiagraph of a fracture of both bones of the forearm in a 
young subject. 



Tab. 7. 



Fig. L 



Fig. 2. 



PLATE YII. 

Fig. I. — Skiagraph of a fractured patella, the two fragments of 
which are widely displaced. 

Fig. 2. — Skiagraph of a fracture of both bones of the forearm in a 
young subject, taken from the same case as fig. i . 



GENERAL CONSIDERATIONS , ON FRACTURKS. 9 

muscles, &c., as possible causes of the patient's trouble.^ 
Frequently the external signs do not at all correspond with 
the extent of crushing- or splintering of the bones beneath, — 
for example, when the foot is run over and the tarsus com- 
pletely crushed whilst the skin is unbroken. A mere fissure 
fracture may be almost impossible to diagnose. The Röntgen 
rays are frequently of much value in the diagnosis of frac- 
tures and in deciding whether they have been correctly put 
up, and the surgeon must reckon upon his patients testing 
the efficiency of his treatment by skiagraphy. 

Sequence of Events in the Hkaltng of Feactuees. 

After a bone has been broken swelling of the soft parts 
around soon follows, due in part to the effusion of blood, in 
part to infiltration of the tissues. The more severe the injury 
the greater will be the swelling, and the amount of the latter 
will also be determined by the amount of blood extravasated 
and the length of time that has elapsed before the fracture 
is put up. These circumstances naturally have some effect 
upon the organism. 

At the site of fracture the bone marrow and other soft 
tissues are crushed up, and from the absorption of these, 
perhaps still more from the influence of the blood-ferments, 
which are also absorbed from the extravasation, we find that 
slight febrile disturbance (rise of temperature, &c.) is pro- 
duced. That blood-ferment, when absorbed, is capable of 
prodvicing fever has been proved experimentally (Angerer). 

Larger or smaller quantities of fat reach the circulation 
from the crushed bone marrow, and are partly excreted by 

' There are some obscure but very important cases of what is apparently 
a peripheral neuritis affecting one or more nerves of a limb, and set up by 
a fracture of a long bone as by other forms of injury. In this way the limb 
may become comparatively or wholly useless as the result of paralysis and 
atrophy of the muscles, persistent neuralgia, trophic changes in the joints, 
&c. Thus in one case spreading neuritis of the whole brachial plexus 
appeared to be due, or at any rate commenced soon after, a fracture of the 
olecranon, which united by fibrous tissue. In this case the ulnar nerve 
seemed to be the first one affected, and the neuritis to have spread up along 
it to the other cords of the plexus. Such cases must not be forgotten in 
considering the possible remote results of a fracture. — J. H. 



10 CHAPTER T. 

the kidneys. For this reason, in many cases, soon after 
the occnrrence of fracture, fatty matter can be detected in the 
patient's urine, together sometimes with albumen and casts. 
In the neighbourhood of the fracture itself the swelling- 
due to the blood effusion and a form of inflammatory oedema 
mny last several days, but in cases properly treated they are 
already on the decrease at the end of a week. The extra- 
vasation of blood then begins to show by its well-known dis- 
coloration, and the stretching of the skin relaxes. When 
there has been great swelling one often notices bullge con- 
taining serum, which do not interfere in any way with the 
progress of the case provided correct treatment is followed ; 
they indicate, however, the necessity for disinfection of the 
skin and the use of an aseptic dressing. Around the site of 
fracture, as the swelling goes down, a rounded swelling of 
almost cartilaginous hardness will be noticed, which gradu- 
ally shades off into the normal bone. 




Fig. 3. — Formation of callus round a. recent fracture of the rib 
without displacement. 

It is a remarkable fact that this process is the rule,- — alike 
ni new-born children and in extreme old age, under normal 
conditions every fracture unites by bone. 

The formation of this callus is almost entirely due to the 
periosteum, which, owing to its being torn irregularly and 
irritated by small fragments of bone, is stimulated into a 
form of periostitis ossificans. The medulla is not wholly 
passive, but shows a slight tendency to form callus, so that 
where the two ends are but little displaced we may notice, 
ist, a ring oF mortar-like external callus; 2nd, the internal 
or medullary callus ; 3rd, connecting these two a very slight 
intermediate callus developed from the bone itself. The 
formation of callus is naturally much more copious when the 
fragments are greatly displaced, and it is least in the case of 
fractures of children when the periosteum has been untorn. 
In cases of complicated fracture there may be sometimes 
necrosis of one or both ends of the fragments. As in 



xa.0. o. 







Fig. 3 c 



Eig.2 



l,ith.A()si V V firidiholil, Miiiicli'.'n 



PLATE VIII. 

FORMATION OF CALLUS. 

Fig. I. — Yerfcical section of a humerus with united fracture. Slight 
displacement. The callus is moderate in amount, and is now formed 
of compact bone. The medullary canal is open, and is only narrowed 
by a few layers of spongy bone. 

Fig. 2. — Vertical section of a tibia, with a fracture united at an 
angle. The former compact circumference of bone has become more 
cancellous, and the medullary cavity is interrupted. 

Figs. 3«, b,c. — Specimens from a case of severe compound fracture of 
the femur. Owing to septic.inflammation of the wound necrosis of a 
complete ring of bone followed and amputation was done, since there 
appeared to be no probability of union. 

Fig. 3 a shows the lower fragment with the main sequestrum. 

Fig. 3& shows the upper fragment in vertical section, so that the 
new periosteal bone and that within the medullary cavity are dis- 
played. 

Fig. 3 eis the sequestrum detached from the upper fragment with 
its stalactite-like projections. 



GENERAL CONSIDERATIONS ON PRACIURES. 11 

necrosis due to osteomyelitis^ the dead part is gradually 
thrown off by a process of rarefying osteitis^ the time re- 
quired for the separation varying from two to six months, 
according to the age of the patient, &c. Meanwhile new 
bone has been produced from both sides by means of ossify- 
ing periostitis so freely that after removal of the sequestrum 
the union of the fracture will be probably quite firm. 

Whereas formerly the production of callus was separated 
into provisional or definitive, we can now only use these 
terms as implying that after the union of a fracture (in the 
ordinary sense of the words), during the ensuing months and 
even years, certain further changes gradually occur which 
alter the anatomical conditions at the site of the fracture. 
In other words, the abundant and spongy callus becomes 
more scanty and firmer, gradually taking on the character 
of compact bone. Absorption takes place of all that part of 
the callus which is not required in the mechanical sense. 
The medullary canal may possibly be restored. These 
gradual changes are illustrated in Plate VIII. 



On Cketain Skvere Complications of Feactures. 

I. Fat embolism has already been alluded to. Whilst the 
absorption of small quantities of fat is of no importance, that 




Fig. 4. — Fat embolisin in the Inng. Fresh preparation prepared 
with sodium hydrate. The fat is shown within the capillaries 
and in isolated drops. 

of larger amounts may be very dangerous and even fatal. 
The fat is set free from the medullary canal, and also from 



12 CHAPTER 1. 

the damaged adipose tissue round tlio bone. Thus fat in a 
liquid condition, at the temperature of the body, can be 
taken dii-ectly into the torn veins of the bone, and so get 
access into the general circulation, — in part also may be 
absorbed by the lymphatics. It is usually arrested as fat 
emboli in the capillaries of the lungs ; if it passes through 
these it may form emboli in the arteries of the various 
organs, — as, for instance, the central nervous system. The 
tre;itment consists in stimulating the heart in order to 
favour elimination of the fat through the kidneys. 

2. Thrombosis of veins and subsequent embolism is a rare 
but very dangerous complication after simple fractures. 
Cases have occurred in which during the healing of the 
fracture sudden symptoms of asphyxia have developed and 
caused death. At the post-mortem examination embolism 
of the pulmonary arteries has been found, consecutive to 
venous thrombosis in the neighbourhood of the fracture. 

In other cases which recovered, the diagnosis of embolism 
of the pulmonary arteries could be made from the clinical 
symptoms. 

Thrombosis of the veins in the neighbourhood of a frac- 
ture, often causes oedema of the limb aifected. This com- 
plication is most frequently seen in the lower extremity 
(usually within three weeks from the date of fracture), some- 
times in comparatively slight fractures, — as, for instance, in 
a recent case of fractured patella. 

3. Wounds of the main blood-vessels are a very rare com- 
plication. They have been most often observed in the case 
of the anterior and posterior tibial arteries ; they may lead to 
profuse hgemorrhage, to aneurism,^ or to gangrene of the limb. 

4. Damage to nerve-trunks may occur in several ways, of 
which examples are met with especially in the case of the 
musculo-spiral and external popliteal nerves. They may be 
injured directly by the force which produces the fracture, 

' Perhaps the most remarkable case of this on record is that figured by 
Sir Charles Bell (' Observations on Injuries of the Spine and Thigh-bone,' 
|)1. iv, fig. 3). A lad had separated his lower femoral epiphysis, which 
united with the edge of the diaphysis, projecting backwards. It was not 
till over twenty years later that the erosion of the artery by this edge of 
bone led to an aneurism requiring amputation. — J. H. 



GEXKK'AL CONSIDERATIONS ON Eh'AGTUIMiS. 



13 



by damage from a displaced fragment^ and finally by impli- 
cation in the callus. Operative interference in the two 
latter cases has frequently been followed by success 

5. Delayed formation of callus. Whereas frequently the 
callus forms in excess^ and occasionally true tumours of 
callus (osteoma^ enchondfoma) develop^ we sometimes observe 
an abnormal retardation of its formation. It is difficult to 
fix on the cause for this. 



Fig. 5. 



Fig. 6. 





fig. 5 — Musculo-spiral nerve thickened where it ran through 
callus of a united fracture of the humerus. The nerve was freed 
by cliiselling away the bone, and the paralysis cured. 

Fig. 6 — Method of producing venous hypersemia at the seat 
of a fracture. An elastic tourniquet is drawn tightly over a linen 
band, and secured by Spencer Wells forceps. The limb is, more- 
over, so bandaged that the efEect of the hypersemia is localised to 
the region of the fracture. 



It is of practical importance to note that with lapse of 
time and appropriate treatment consolidation of the fracture 
is almost always arrived at. 

Amongst the measures to be taken are — (i) generous diet^ 
&c. ; (2) allowing the patient to be up and have the frac- 
tured limb dependent in suitable splints ; (3) the production 
of hyperasmia at the site of fracture by means of elastic 
bands or bandages above and below (Fig. 6) ; (4) still more 
active treatment in the form of rubbing the fractured ends 



14 



GHAPTEE I. 



together, and introducing pegs into the fractured ends in 
order to produce stronger reaction. 

6. By pseudarthrosis is understood a new false joint at the 
site of fracture. True pseudarthrosis must imply the forma- 




Fig. 7. — Pseudarthrosis with fibrous union of the ulna (after 
Bruns). 

tion of a joint cavity and capsular membrane. Now-a-days 
this complication can usually be prevented or cured by 
operation. 

The formation of a pseudarthrosis may depend upon 
general or local causes : of the former, syphilis and general 






''>^. 



<^.. 



Fig. 8. — False joint after fracture of the humerus. Of the two 
ends of the bone one is somewhat knobby ; the other forms a 
kind of a cup. The articulation is surrounded by a true 
capsule, presenting a villous surface. 

debility are the chief ; of the latter, for instance, the callus 
may be deficient, owing, perhaps, to the fracture having been 
comminuted and compound, and much bone having been lost. 
In other cases, even with normal formation of callus, a false 
joint may result from interposition of soft parts, or wide 
separation of the fragments. The interposition of the soft 



GENKEAL CONSIDERATIONS ON FKACTUKES. 15 

pai'tSj and especially of muscle bauds (e. (j. in the case of 
fracture of tlie femur or humerus)^ is an absolute hindrance 
to bony union. The diagnosis of this complication in a 




r*s 



\ 



Fig. 9. — Dry specimen oE a complete fiilse joint. From the 
same specimen as Fig. 8, only macerated. Tiie medullary 
cavity was quite closed at either end. 

recent fracture can be made occasionally by the marked 
movement of the fragments when the implicated muscle 
contracts^ or perhaps better by the absence of crepitus. In 
such cases energetic attempts to dislodge the interposed 
muscle, &c.,if necessary by operative interference, are strongly 
to be recommended. Marked over-riding of the fragments 
is especially seen in the case of the humerus and femur ; and 
here, although much callus be formed, no real union may 
be present. It is hardly necessary to point oat that imper- 
fect immobilisation is here of considerable importance. 

In the treatment of pseudarthrosis operative removal of 
the interposed tissues, resection of the ends of the fragments, 
and suture by silver wire may lead to a cure. Transplanta- 
tion of bone may also be iTseful. 

7. Suppuration at the site of a simple fracture [i. e. in the 
surrounding extravasation of blood) may occur without the 
smallest wound of the skin, or without the presence of any 
point of infection (furuncle, &c.). 

8. Delirium tremens is a serious complication of fractures 
in alcoholic subjects, and should it occur it may be necessary 
to fix the fracture in plaster of Paris strengthened with steel 
bands. The patient, who is rendered by his delirium uncon- 
scious of pain, should be carefully watched lest he get out 
of bed, aud narcotics should be used with great care. As a 



16 



CHAPTER. I. 




Fig. lo. — Old pseudarthvosis in the left forearm resulting from 
severe fracture and loss of bone in early life. 

The patient, a man aged forty-four, broke, when he was a child 
of eight, his left forearm in several places as the result of a fall. 
Pieces of bone came away , and it was only after nine months' treat- 
ment that healing resulted, though the arm remained almost useless. 
At the present time there is ankylosis in the left elbow, and the 
fingers are fixed in a flexed position. The left forearm is ii cm. 
(4^ inches) shorter than the right. There is a false joint at the 
junction of middle and lower thirds. In the peripheral part the 
ulna is wholly wanting, the radius alone remaining. If not 
supported it falls with the hand in a helpless manner. The 
patient uses a kind of splint devised by himself, and manages 
then to move the thumb slightly towards the ankylosed fingers. 
De])ressed scars are present at the site of fracture and at the elbow. 
Probably the fracture was compound from the first, wide-spread 
suppuration followed, and the lower end of the ulna had to be 
removed. The joints of the hand and the tendon sheaths have all 
stifEened. 

prophylactic measure the alcohol to which the patient is 
accustomed should not be wholly left off, and care taken that 
he does not pass a sleepless night. ^ 

^ As soon as the symptoms which foreshadow an attack of delirium 
tremens (tremor of hands or tongue, increased pulse-rate, restlessness, 
purposeless movement of the hands, air of suspicion, or commencing delu- 
sions) are observed, prompt measures should be taken to avert the attack. 
If the patient is not already taking beer or stout he should be given a 
moderate quantity, together with a sedative such as bromide of potassium 
grs. XX to grs. xxx, and chloral hydrate grs. x to grs. xv, every four hours. 
In addition he should be induced to drink fluids, such as water, freely. If 
the bromide is alone relied on it may be given in still larger doses. — J. H. 



GENEEAL CONSIDERATIONS ON FRACTURES. 17 



Prognosis of Fracturks. 

Prognosis of simple fractures is very favourable except in 
very old or feeble patients^ and unless the complications 
mentioned above supervene. With fracture of the lower 
limbs in old people a considerable proportion die of hypostatic 
pneumonia. As to the effect upon the usefulness for work 
of certain special fractures^ we have only lately obtained 
numerical information. It was, of course, known that con- 
solidation followed sooner in healthy individuals^ after 
thorough overcoming of the displacement. One knew also 
that the prognosis was more unfavourable in the case of spiral 
fractares (on account of extensive damage to the medullary 
cavity) J and of direct fractures on account of simultaneous 
damage to the soft parts. It was also known that long- con- 
tinued lest of an extremity led to atrophy of the muscles and 
to stiffness, with other changes in the immobilised joints, but 
more exact knowledge has only lately been obtained on the 
subject. 

A patient with a fracture may be said to be cured only 
when he is ngain able to work; fractures cause only too 
often persistent incapacity for work. Out of 121 cases of 
fracture of the shaft of the femur, 34 per cent, were com- 
pletely cured in this sense, whilst 66 per cent, remained per- 
manently damaged. The average duration of time before a 
cure was obtained was 13^ months. Out of ig cases of frac- 
tured neck of femur 12 per cent, died, 12 per cent, were cured, 
and 76 per cent, sustained permanent damage. Out of 148 
cases of fracture of the leg bones, 78 per cent, were com- 
pletely cured ; out of 30 cases of fracture of the humerus, 
72 per cent. ; out of 67 cases of fracture of the forearm, 87 
per cent, were cured. The causes of these unfavourable 
results and of the long period of time required for the treat- 
ment are to be sought in the following : displacement of the 
fragments, stiffness of the neighbouring joints, sometimes 
hypertrophy of the callus, delayed union, pressure on nerves, 
persistent pain, and oedema of the limb. These facts 
emphasise the teaching that the details of treatment are all- 
important in the ultimate result. Not only in the case of 

2 



18 



OHAPTBE I. 



compound fractures, but also in that of simple ones, the fate 
of the patient rests in the hands of the surgeon. 



TU'KATMENT OV FeAC'1'ÜRKS. 

{Note. — Some observations on the importance of obtaining exacb reduc- 
tion, &c., have been omitted, as being too rudimentary to require translation.) 

There is real danger in applying plaster-of- f'aris bandages 
around a limb recently fractured, and many disasters have 
occurred from disregarding this rule. The swelling of the 
tissues under the plaster, and the contraction of the latter, 
may lead to complete angemia of the muscles, and their 
permanent shortening and atrophy (see Fig. 12) ; or to 
gangrene of the limb from complete stoppage of the arterial 
flow (see Fig. 11). In the former case, whilst the response 




Fig. II. — Gangrene of tlie leg following the treatment of a 
simple fracture by a tight plaster-of-Paris bandage, which was 
applied immediately after the accident, and only removed twenty- 
three days later, in spite of the toes having been at first purple, 
then black, and the part extremely painful. At the end of four- 
teen months the gangrenous end had not yet separated. 

to direct galvanic stimulus of the muscles is more or less 
completely lost, that of the nerve-trunks may be retained 
intact. 

In the treatment of fractures by splints, those made of 
beat metal and the moulded plaster-of-Paris ones are 
strongly to be recommended. 

In the use of all forms of apparatus, it must never be for- 
gotten that pressure is not to be applied directly over the 



GENKRAI, CONSIDERATIONS ON FIJAOTURES. 19 

Fig. 12. Fig. 13, 





Fig. 14. 



Fig. 15. 




Fig. 12. — Paralysis and contraction of tlie forearm muscles in a 
lad aged seventeen, which had resulted from the application of a 
tight plaster-of-Paris bandage, ten years previously, over a frac- 
ture of the lower end of the humerus. 

Pig. 13. — Splints made out of bent metal, applied to a fracture 
of the lower end of the humerus. 

Pig. 14. — Plaster-of-Paris splint being cut open along the 
side. 

Pig. 15. — Saw for cutting open plaster-of-Paris splints. 



20 



CHAPTER I. 




Fig. i6. — Plaster-of- Paris splints, the edges of which are 
trimmed with sticking-plaster. 

fracture^ since this method of attempting to reduce a dis- 
placement is unsatisfactory and dangerous. Treatment by 
weight extension is not only useful in the case of fractures 







Fig. 17. — Application of plaster- of -Paris splints to the leg 
and foot. 

of the femur, but also in some examples of fracture of the 
humerus. For this purpose a combination of india rubber 
bands and strapping is often of use (see Fig. 18). 




Fig. 18. — India-rubber band with strapping sewn to either 
end, used in obtaining elastic traction. 

Certain methods of treatment of particular fractures are 
adapted for use in specially skilled hands, but not in my 



GENERAL CONSIDERATIONS oN FRACTURES. 21 

opinion for general practice. It cannot be doubted tliat the 
open method of suture of a fractured patella gives remark- 
able results in the hands of skilled surgeons ; and again^ for 
example^ the treatment of Colles's fracture without the use of 
splints at all.^ 

When the opportunity is afforded by the readjustment 
of splints^ massage and passive movement should be em- 
ployed to the imprisoned joints, and after the fracture has 
united they are both of importance, together with warm baths 
and careful bandaging and the use of mechanical apparatus. 
We have to specially notice the treatment of fractures into 
the joints, involving extravasation of blood into the latter. 
The problem to be solved includes securing firm union of 
the fracture with a moveable joint ; in such cases frequent 
change of dressings every two to three days during the first 
fortnight, and after that daily, is to be recommended. 

In order to obtain absorption of the blood, if aspiration is 
not employed, careful bandaging over the joint and massage 
and passive movement on the occasion of each change of 
dressing, the fixation of the limb in different positions, and 
the early use of active movement and mechanical apparatus, 
are to be recommended. The carrying out of such treat- 
ment involves great patience on the part of the surgeon, but 
it is extremely satisfactory in such a case to obtain good 
movement of the joint after the fracture is united." 

A few words must be said about badly united fractures. 
In spite of every. care, it may befall any surgeon to be dis- 
appointed with the results of his treatment, and the stupidity 

' To dispense witli splints and to employ massage from an early date in 
cases of various fractures, such as those of the fibula, is an apparently novel 
suggestion, which Lucas Championniere and others have brought forward. 
But the practice has been in vogue amongst the Hottentots and other 
African races for very long as the routine method of treating fractures. 

^ In the case of a fracture through a joint (e. g. the elbow or knee) the 
best plan is to fix the fragments in as good position as possible, and keep 
them at rest until sufficient time has elapsed for union to take place, and 
then for the first time to employ passive motion. If the latter is carried 
out at frequent intervals during the first fortnight, as suggested above, the 
process will be very painful, and may lead to non-union or to excessive 
callus. In these cases passive motion begun too early simply defeats its 
own object. — J. H. 



22 



CHAPTER I. 



or carelessness of some patients may account for some cases 
of fracture united with deformity vvliicli come to us for 
further treatment. In these cases it is best without further 
loss of time to re-fracture the bone, either by means of an 
osteoclast or an osteotome, and to obtain better position by 
manual pressure, weight extension, &c. 




Fig. 19. — Rizzoli's osteoclast. 



Fig. 20. — Intra-capsular fracture of 
the neck of the femur, resulting 
in non-union. Specimen seen from 
behind. 



On Dislocations. 

(The greater jiart of tliis section has been omitted, on account of its being 
only rudimentary.) 

After reduction of a dislocation and appropriate fixation 
of the part the extravasation and slight synovitis due to the 
injury disappear in from eight to fourteen days. As soon as 
possible, even before this time has elapsed, massage and 
passive motion should be begun, to be abandoned for a lime 
if pain and signs of inflammation of the joint come on. 
After three weeks have elapsed it is usually safe to allow 
active motion.^ 

' It is desirable to exercise much caution with regard to allowing active 
motion from the fear of a re-dislocation. This holds true particularly of 



GKNElvAI- CONSIDERATIONS ON ERAUTÜRKS. 23 

shallow or ill-protected joints, such as the shoulder. The rent in the 
capsule is repaired but slowlj, and even many weeks after the reduction it 
is possible, in a sudden movement whereby the arm is raised and abducted, 
for the humeral head to again leave its socket. I have had to give 
evidence in a law case where the re-dislocation had occurred at least three 
months after the first accident. Heavy damages were claimed by the 
plaintiff, who had been specially warned of the risk from abducting the 
arm vigorously. If a re-dislocation once occurs it may be expected to recur 
again and again. 

Do true dislocations occur in infancy and early childhood? 

Although separation of the epiphyses to a considerable extent takes the 
place in very early life of true dislocation, there cannot be the slightest 
dpubt that genuine cases of the latter may occur even at birth. 

It was formerly suspected that congenital dislocation of the hip was due 
often to violent manipulation during delivery ; but this theory has nothing 
to support it, and is most improbable, seeing how often the dislocation is 
symmetrical. During parturition the arms of the infant are much more 
likely to be damaged than the lower limbs, and cases of fracture of the 
clavicle, dislocation of the humerus, and fracture of the latter bone are not 
very infrequent from this cause. Separation of the upper epiphysis during 
labour may also occur. If overlooked, and not correctly treated, these 
injuries may produce the most serious results on the arm affected, and it is 
very easy to overloolc them in young fat infants. 

Cases of true traumatic dislocation in young children affecting almost any 
one of the chief joints in the body could readily be adduced. Thus Pow- 
drell reports a case of tliyroid dislocation of the hip occurring in an infant 
aged six months, and readily reduced by manipulation. 

By far the commonest true dislocation in young children is the subluxa- 
tion of the radial head, which, unlike all other dislocations, is confined to 
children under five year.« of age. — J. H. 



CHAPTER II. 

^EAUTUUKS OP THE CEANIUM, SPINE, E'l'C. 

In considering the subject of fractures of the skull, both 
vault and base, it is of interest to note the elasticity of the 
bone, for it is only after a force has exceeded the limits of 
this elasticity that a fracture can take place. It is well 
known that the inner table is usually more widely splintered 
than the outer one, and an attempt has been made to explain 
this by a greater fragility of the inner table. It is now 
known that the fact is to be explained by simple mechanical 
considerations, and that when the force acts from within 
(e. g. by a bullet passing through the skull), the outer table 
in its turn will be more widely fractured than the inner one. 
The blow causes a bending inwards of the table first com- 
pressed, which bending leads to a dissemination of the force 



A 




c d 



B A- 




Fig. 21. — The segment of the skullt B has been struck at the 
points a b. Owing to its elasticity it has taken the form Ä' B'. 
Hence the particles of bone at a h have been squeezed together, 
whilst the corresponding portion of internal table at c d has 
been stretched and the particles torn asunder. The result will 
be understood from comparing the quadrilateral a b c d in the 
two figures. 



and wide-spread splintering. Plate IX and Fig. 21 explain the 
preceding statement. 



Tab. 9. 




w«H*«i«ikiw«jipi«piiiNPP' ' " 



Figßcu 



Lilli./iri.st.v. F. Roiclüiold , Müriihm . 



PLATE IX. 

FRACTURES OF THE VAULT OF THE SKULL. 

Fig. I. — Bullet perforations made from without and from within, as 
indicated by the arrows. It will be seen that the aperture of entrance 
is circular and much smaller than the aperture of exit, which latter is 
irregular in shape. 

Fig. 2. — Fracture produced by a bullet fired with so little force 
as not to perforate the skull. It will be seen that the outer table 
is merely slightly depressed, but that the inner table is widely 
splintered. 

Figs. 3 a, b, c. — An old depressed fracture of the skull. Here again 
it will be noted that the inner table is the most widely broken. 



OS 








ii4. * 






PLATE X. 

BULLET PRACTUEES OF THE SKULL. 

Figs. I and 2 show the front and back aspect of a skull traversed by 
a bullet fired from an ordinary German infantry rifle at a distance of 
200 yards. Tbe aperture of entrance is much smaller and more regular 
tban that of exit. There are wide-spread radiating lines of fracture 
around both. 



Tab. 11. 




t^iCL 




/It; 




-'^' 



Li/, ä -' 



LitkÄnsiv. F.Reiclihöld, Münchsn 



PLATE XI. 

These figures are somewhat diagvammatic, being founded on a museum 
specimen, and on a patient who recovered from the accident. In the 
latter case he had been struck by a brick on the left temporal region 
and the vertex of the head, sustaining a fracture complicated by de- 
pression of the bone, and a gap which gaped widely, together with 
effusion of blood between the dura mater and the bone, from rupture 
of the middle meningeal artery. The blood-clot is well shown in 
fig. I a. 

Fig. I h shows the fractvire running up along the coronal suture, but 
ending as a fissure which bends off into the parietal bone. 



FI(ACT[Jßt;S OF THE VAULT OF THE SKULL. 25 

It will be understood that it is possible to produce an 
isolated fissure of tlie internal table by means of some blunt 
instrument^ &c., without any fracture of the outer table, 
and the converse statement may even hold true with regard 
to the outer table. On the other hand, if the force be 
exerted by a sharp instrument the outer table alone may be 
depressed or fractured ; this has been repeatedly observed 
in the case of sabre wounds and the like. 

More common than the fractures of the internal table 
alone are those in which the outer table sustains some slight 
lesion (fissure or groove) whilst the inner table is widely 
splintered, and the splinters project inwards towards the 
cavity of the skull, like the rafters of a roof. Sometimes a 
breach of conti nuitv in the vault of the skull occurs in the 




K^^> 



\; 



Fig. 22. — Experimental bullet perforation from within of vault of 
the skull. It will be seen that the piece of bone driven outwards 
has somewhat the shape of a mushroom when looked at from the 
side, whilst viewed from above it has the appearance of a rosette. 
I have several times observed this appearance. 

line of a natural suture,^ The freatment of depressed frac- 
ture of the skull with wound of the soft parts involves careful 
disinfection of the latter, which will be best done by cutting 

1 The venous sinuses in relation to fracture of the skull. — Both the 
lateral and superior longitudinal sinuses may give rise to very serious 
haemorrhage from rupture due to fracture, or from a wound during the 
operation of trephining. It is quite impossible to stop the bleeding by 
ligature, and the only treatment consists in plugging with antiseptic gauze 
and direct pressure. Improbable though it may seem, it is yet possible for 
a man to recover after having one lateral sinus freely opened by a sabre 
wound on the field of battle (see Specimen 868, Museum Royal College of 
Surgeons). — J. H. 



26 CHAPTER Tl. 

away the damaged and infected edges of the scalp wound 
with scalpel and scissors : after this the depression must be 
elevated ; this usually implies trephining at the edge of the 
fracture. It is important to remove all sharp fragments of 
bone, especially since septic particles from outside {e. g. hairs) 
are often driven in between them. This fact I have re- 
peatedly observed in the macerated preparations at Leipzig 
and Munich^ and it will be understood that the force at the 
time of the accident may wedge these hairs firmly between 
the fragments^ and thus lead to meningitis by septic in- 
fection. 

If the fracture is subcutaneous the indications for opera- 
tion are much less clear. We know now, contrai-y to what 
was lately taught, that a depression producing a considerable 
diminution in the capacity of the skull may have little or no 
bad effect on the brain ; nevertheless such a depression may 
later on exceptionally lead to such symptoms as Jacksonian 
epilepsy, for which an operation may become necessary. 

1 Hernia cerebri. — Hernia cerebri is a most important complication of 
compound fractures of the skull, but one whicli has of late become much 
rarer owing to surgical operations being more frequent on depressed frac- 
tures, and to aseptic precautions (see an important review of the subject by 
Lawford Knaggs, ' Med.-Chir. Trans.,' 1897, pp. 249—302, with abstracts 
oE over a hundred cases ; three fourths of these were due to compound 
fracture). The following deductions may be drawn : 

1. Hernia cerebri always means inflammatory softening of the brain to a 
varying depth, but by no means always implies an abscess within the skull. 

2. Its chief dangers lie in the development of cerebral abscess and of 
general meningitis, the latter often the result of injudicious surgical inter- 
ference. 

3. The symptoms due to cerebral abscess (coma, paralysis, &c.) may be 
of extremely rapid onset, and cause death in a few hours. Prompt evacua- 
tion by trocar or tenotome and drainage is demanded. 

4. The prognosis of recovery in cases of hernia cerebri treated by asepsis, 
but otherwise left to nature, is probably 50 per cent. 

5. In its treatment pressure is useless and dangerous, and apart from 
the use of antiseptics other surgical treatment is liardly ever required 
unless an abscess requires evacuation. 

6. In all operations on compound fractures of the skull, &c., the surgeon 
should endeavour by strict asepsis, the suture of divided dura mater, and the 
replacement of viable fragments of bone from which all sharp angles have 
been cut off, to prevent the later development of hernia cerebri. — J. H. 




Figl 





Fig. 3 



Liih.tastv. F. Reiöhholii . MiinctiFn 



PLATE XII. 

VARIOUS rBACTUEES OF THE VAULT AND BASE OF THE SKULL. 

Fig. I. — Vault, with a fissure traversing the frontal bone, and a 
starting of the suture between the temporal and parietal bone. 

Fig. 2. — Fracture of the base of the skull from pressure against the 
spine due to a fall on the head. The fracture is all round the foramen 
magnum, and some pieces of bone have been lost in maceration. 

Fig. 3. — Antero- posterior section through the base at the level of 
the temporo-maxillary joint (normal). The drawing shows the rela- 
tions between the condyle of the jaw and the thin poition of bone 
above it. 



FRACTÜKES OF TUE BASE OF THK SKULL. 27 



Fractoees op the Base of the Skull. 

It is easy to understand that, fractures of tlie base of tlie 
skull chiefly follow indirect violence ; a direct lesion of the 
base from ordinary violence is only possible at the roof of 
the orbit and the nose, but gunshot injuries may naturally 
implicate the base of the skull at any spot. Formerly it 
was the custom to invoke the theory of contre-covp to explain 
fractures of the base^ but with advancing knowledge this 
theory has receded more and more into the background. 
Careful study of fractures of the base and many experiments 
on the dead subject have shown that fractures of the base 
from indirect violence present a certain regularity of form, 
and can be explained in a particular way. This holds good 
naturally for those cases which have resulted from a moderate 
degree of violence; where a tremendous crushing force has 
been applied there can be no regularity in the lines of 
fracture. The following points are of importance in explain- 
ing the form and direction of fractures of the base. First, 
the base may be considered as the weakest part of the skull. 
This is only true to a certain extent, since along with the 
thin and almost translucent areas, which, moreover, present 
large openings for nerves and vessels, we find here strong- 
parts of bone which to a certain extent act as buttresses. 
As such we have to notice the petrous bone on either side, 
and the ridges bordering the sphenoidal wings. These 
pillars converge towards the pituitary region and the front 
edge of the posterior fossa. Observation shows that fractures 
of the base pass transversely by preference between these 
pillars. Nevertheless it is common enough for the petrous 
bone to be itself involved. Second, by far the greater part 
of fractures of the base commence above in the vault, i. e. 
from the point where the force is ap23lied, and run thence by 
the shortest route to the base ; and since the force is most 
commonly applied to the top of the head, the fracture will 
usually implicate the middle fossa. Third, a certain pro- 
portion of fractures of the base arise in an indirect manner, 
owing to one or other of the face bones or of the vertebrae 
being driven into the base. This may, for instance, occur 



28 CHAPTKR Tl. 

when a patient falls on his feet or in a sitting posture ; the 
fractures then radiate from the foramen magnum, and are 
very characteristic in appearance. They can be produced 
by experiment on the dead body. In a similar manner to 
the action of the vertebrge, the bones of the face may be driven 
inwards so as to produce fracture of the base (see Plate XIII) . 
On Plate XII, fig. 3, it is seen that just above the condyle 
of the jaw the bone is very thin, and occasionally it is frac- 
tured by the jaw being driven upwards ; but this is rare on 
account of the jaw itself usually breaking, and of the bone 
immediately round this thin spot being so strong as to protect 
it. Fourth, in very rare cases a fracture of the base is pro- 
duced by extreme compression of the skull. The fracture 
then will be either longitudinal or transverse to the long axis 
of the skull according to the direction of the compressing 
force. In such cases the lines of fracture are not always the 
same, but taken as a whole are fairly characteristic (see 
Plate XIY). Isolated fractures of the orbital roof, and more 
rarely of other parts of the base, cannot readily be explained ; 
but the influence of hydrostatic pressure may be invoked, and 
it is not to be wondered at that when severe pressure is exerted 
on the whole skull the thinnest part of it may crack. 

The symptoms of a fracture of the base naturally vary ac- 
cording to the extent and position of the fracture. Of 
importance in diagnosis are the following : 

I. First, haemorrhage. When it occurs under the skin 
it is of no diagnostic importance unless the injury was 
inflicted at some distance from the site of the haemorrhage. 
In the case of fractures of the anterior fossa of the cranium, 
extravasation into the orbit is of some importance, since 
nearly all such fractures are attended with more or less 
bleeding into the fatty tissue of the orbit, and this extrava- 
sation after a certain time extends into the lids and con- 
junctiva. It is of especial assistance towards a diagnosis 
when there is no injury in the region of the forehead. Pro- 
trusion of the eye due to the extravasation is very rare, as 
also is a hEematoma under the mucous membrane of the nose ; 
more common is epistaxis, which may readily lead to hsema- 
temesis. 

In the case of fractures of the middle fossa and temporal 



Tab. io. 




Ei^.1 




Lith.Aiisi, V, F, Rcichliold , Miiiirlier, 



I 



PLATE XIII. 

FKACTUEE OF THE BASE OF THE SKULL FEOM INJURY OF THE 
NASAL REGION. 

The preparations were obtained from the body of a man aged twenty- 
eight, who was admitted into the Leipzig Hospital with the diagnosis 
of fracture of the nose, and who died of meningitis. 

Fig. I shows impaction of the nasal and part of the ethmoid bone, 
which project into the interior of the cranium. 

In fig. 2 the same is indicated from the fi'ont, and the complicated 
nature of the fracture shown. 



Tau. 14. 




%.2 




Fa^.1 



Litli./'\iisi .V. }\ R,p ichhold . MCinchm , 



PLATE XIV. 

FEA.CTUEE OF THE BASE OF THE SKULL. 

Fig. I. — Fracture of the base from antero-posterior pressure. The 
patient, a man aged thirty-five, sustained a fall of ten feet on his head. 
At the autopsy this fracture, passing through the foramen magnum, 
was found. (From Hutchinson's ' Illustrations of Clinical Surgery,' 
vol. i, pi. XXX.) 

Fig. 2. — ^Transverse fracture of the base of the skull produced 
experimentally on the dead subject by forcible pressure exerted across 
the skull. The result is precisely analogous to that shown in fig. i. 



PEACTÜRES OF THE BASE OF THE SKULL. 29 

bone^ bleeding from tlie ear is often observed, and naturally 
a fracture of the base to cause such bleeding must rupture 
the membrana tympani. In the diagnosis we have to re- 
member the possibility of entrance of blood into the ear from 
outside, rupture of the membrana tympani, or a fracture of 
the anterior or posterior wall of the bony meatus without 
implication of the cranial ba<e. In the case of fractures of 
the posterior fossa, an extravasation around the mastoid pro- 
cess appearing some days after the accident is of some 
diagnostic importance. 

2. Escape of brain matter is met with but seldom, and 
only in the worst cases of fracture. Of course, when it does 
occur, it is a sure sign of fractured skull with simultaneous 
rupture of the dura mater and crushing of the brain. The 
escape of cerebral matter from the ear is, perhaps, more 
frequently met with than elsewhere, though much more often 
it is the cerebro-spinal fluid which exudes. This occurs after 
the cessation of haemorrhage from the ear {i. e. within twenty- 
four hours after the injury) , A considerable amount of fluid 
usually escapes, and one can collect it drop by drop in a 
test-tube. The fluid is clear (when free from blood), of 
alkaline reaction, precipitates but little on boiling ; it con- 
tains hardly any albumen, but some sugar and a great deal 
of sodium chloride. Such an escape of serous fluid is a 
sure sign of fracture of the base and rupture of the mem- 
branes, but is a much rarer symptom than hgemorrhage from 
the ear. 

3. Lesions of the nerves passing through the base of the 
skull. If this symptom is observed directly or soon after the 
accident, one suspects a tear or crush of the nerve involved 
within its bony canal. If the paralysis of one or more 
cranial nerves comes on later, it may be tlie result of an in- 
flammation spreading from the outer surface of the skull, 
which may lead to fatal basal meningitis.^ The nerves most 

' Professor Helfericli, in the original, makes this statement even stronger, 
i.e. that such paral^'sis of deferred onset is always the result. However, we 
see sometimes facial paralysis coming on a week or more after a fractured base, 
and ultimately clearing up more or less completely, without any evidence of 
its being due to meningitis. In one such case in which the patient died a few 
weeks after the accident (though not from meningitis) the nerve was found 



30 CHAPTER II. 

frequently injured in fractured base are the facial and the 
auditory, a fact easily explained by their course through the 
petrous bone, and the frequency of fractures in this region. 
Köhler observed in 48 cases of fracture of the base that facial 
paralysis was present 22 times, and paralysis of the sixth nerve 
only twice. Battle recorded, out of 16S cases of fractured base, 
tearing of the olfactory nerve in 2 cases, paralysis of the sixth 
nerve 5 cases, [)aralysis of the facial nerve i 5 cases, paralysis 
of the auditory nerve 14 cases, blindness from extravasation 
of blood in the optic nerve sheath 8 cases. ^ 



The Couesk and Prognosis op Fractuhes of thk Base. 

Whilst it was formerly believed that fractures of the base 
were invariably fatal lesions, we know now through clinical 
and post-mortem observation that these fractures may be 
recovered from if they have not been complicated by too 
severe crushing of the brain, or intra - cranial haemorrhage. 
Evidence of damage to the brain is seldom wanting in cases 
of fractured base, the slightest form thereof being due to 
a shaking of the brain (commotio cerebri), a condition indi- 
cated by loss of consciousness, vomiting, and disturbance of 
the heart's action (usually slowing of the pulse). The sym- 

to be inflamed within the aqueduct of Fallopius as it beut downwards. (Orig. 
obs.)— J. H. 

^ Optic neuritis after fracture of the sJculL — This symptom, though not 
common, is of much interest. When it develops several days have 
always elapsed from the date of injury. It may occur (i) with septic 
meningitis from fractured base, &c. ; (2) with abscess of the brain following 
compound fracture oO the vault ; (3) with laceration of the brain accom- 
panying fracture of the base ; and (4) following concussion without evidence 
of fracture. 

Many times optic neuritis has been observed in cases of injury to the 
head which have perfectly recovered. In some of tliese probably tliere is 
a mild form of inflammation at the base of the brain spreading to the 
sheath of the optic nerves (Edmunds and Lawford, 'Trans. Ophth. Soc,,' 
vol. ii, p. 208; ibid., vol. v; and Battle, 'Brit. Med. Journ ,' July, 1890). 

Optic neuritis after injury to the head may be unaccompanied by any 
defect of siglit that is noticed by the patient; on the other hand, blindness 
of one or botli eyes may result from laceration of the optic nerve or htemor- 
rhase into its sheath due to fractured base — J. H. 



Tab. 15. 



•..>v<f*'«' 





2 



IttKibist.v. F. RadMd, München 



PLATE XV. 

FRACTURE OF THE SKULL "WITH RUPTURE OF THE MIDDLE 
MENINGEAL ARTERY. 

Eig. I.— From a workman aged twenty, who fell from the fourth 
story of a house. On admission into the hospital there was an ex- 
travasation of blood in the left temporal region, a perceptible fracture 
of the squamous portion of the left temporal bone, followed by escape 
of cerebro-spinal fluid from the left ear and paralysis of the left side of 
the face, and of both arm and leg on the right side. Death resulted 
from tetanus due to infection of a contused wound in the thigh. The 
drawing shows the position of an extravasation of blood from the 
posterior branch of the middle meningeal artery, together with the 
bifurcation of this artery, the line of fracture, &c. 

Fig. 2. — Horizontal section through the skull with the contained 
brain. There is a large extravasation of blood from the middle menin- 
geal artery, between the brain and the dura mater. This has been 
caused by a fracture through the temporal bone; the brain is com- 
pressed and displaced inwards. (From Hutchinson's ' Illustrations of 
Clinical Surgery,' vol. ii, pi. liv.) 



FRACTÜEES OF THM BASE OF THE SKULL. 31 

ptoms soon clear off^ and in any case^ if the unconsciousness 
lasts more than a few hours^ or at most one to one and a half 
days, a more severe lesion of the brain is to be suspected. 
Sometimes the patient is found to have lost all recollection 
of the events immediately preceding the accident. 

Uncomplicated cases of shaking of the brain are less 
common than used to be supposed. Shaking of the brain 
from side to side within the skull is unlikely to occur ; and 
much more probable^, as a result of severe force acting on the 
skull, is a general squeezing of the whole brain, especially 
when one recollects the elasticity of the skull. Where this 
squeezing force is applied there are probably actual contu- 
sions and extravasation of blood in the cortex, followed per- 
haps by well-marked softening. These definite anatomical 
changes may also be present at the opposite part of the brain 
to the seat of injury. 

According to the importance of the cortical area affected, 
characteristic nervous symptoms from damage of certain 
centres may be present. If there is crushing of the brain, 
and intra-dural hsemorrhage in the region of the anterior and 
middle fossae of the skull, great elevation of temperature (not 
due to meningitis) may be expected. 

We have now to note covipression of the hrain. It has 
been thoroughly made out from clinical observation and ex- 
periments that a relatively large part of the skull must be 
driven in, in order to produce the symptoms of compression 
of the brain. The most typical cases of the latter are due to 
rupture of the middle meningeal artery, followed by extrava- 
sation of blood between the dura mater and the bone, which de- 
presses the surface of the brain as shown in Plate XY, fig. 2.^ 

^ Hseraorrhage from the middle meningeal artery in most cases puslies 
the dura mater inwards opposite the temporo-sphenoidal lohe in the iniddle 
fossa of the skull. It reaches inwards as far as the large foramina for the 
branches of the fifth nerve, but never extends across the middle line It is, 
however, possible for an extra-dural haemorrhage to be present on botli sides 
on the same patient, owing to a rupture of both meningeal arteries. There 
is a specimen illustrating this in the London Hospital Museum. In this 
case the surgeon trephined on both sides, and secured the bleeding vessels by 
ligatures passed through the dura mater. There is no doubt that the 
violent compression of the skull when the fracture occurs may force the 



32 CHAPTER II. 

In typical cases of this kind the early symptoms of concussion 
clea,r off, the patient recovers consciousness, and seems to be 
on the high road to recovery, when fresh symptoms super- 
vene ; at first those of cerebral irritation, and later those of 
paralysis, followed by renewed unconsciousness, slowing of 
the pulse, and fiaally deep coma. In such cases trephining 
over the site of extravasation, and if necessary ligature of the 
torn meningeal artery, can alone save the patient.^ 

For the preceding reasons (without considering their rarer 
complications) fractures of the base are attended with a high 
mortality ; those of the middle fossa are by far the most 
frequent, but cases of fracture through the posterior fossa 
are on the whole the most fatal. 

dura mater away from the bone, and thus favour meningeal hsemorrhage. 
In fact, by this means a fatal rupture of the meningeal artery may be 
produced without a fracture of any part of the skull. This happened in 
the case of a young girl on whom I operated by trephining and subsequent 
ligature of the external carotid artery (see ' Med. Press and Circular,' 
Dec. 15th, 1895). 

If the fracture is chiefly of the upper part of the skull, a meningeal 
branch may be torn, and blood poured out towards the vertex, i. e. wholly 
above the level of the ear. These cases are of particular interest since the 
usual symptoms may be considerably modified, and, further, it may be 
necessary to trephine at a point higlier and more posterior to the one usually 
recommended. — J. II. 

' The symptoms due to hsemorrhage on the surface of the brain may be 
identical with tliose from rupture of a meningeal artery. Hence if tre- 
phining has been done in a case of compression following fracture which is 
supposed to be due to rupture of this artery, and yet no blood is found 
outside the dura mater, the surgeon is justified in incising the latter, and he 
may succeed in letting out an extravasation in the subarachnoid spaces. 
Althougli the prognosis is nece-ssarily very bad, owing to the fact that the 
blood is usually spread out over a large area and towards the base, and 
because of the accompanying injury to the brain, now and then the 
patient's life would be saved by trephining. It is noteworthy that in these 
cases of surface laceration and hsemorrhage there is often marked rise of 
tempeiature, which before the patient's death may reach 105° to 108''. The 
same phenomenon is observed in some cases of steadily increasing hsemor- 
rhage from the meningeal artery, and has nothing to do with meningitis. 
It is not observed in those cases of fracture of the skull which are fatal 
within a few hours of the injury. In order to produce it the extravasation, 
whether on the inner or outer side of the dura mater, must be gradually 
poured out. —J. H. 



FßACTÜßKS OF THK BASE OF THE SKULL. 33 

Treatment. — As a rule this consists, in uncomplicated 
cases^ in keeping the patient perfectly at rest^ applying cold 
to the head^ perhaps feeding with the oesophageal tube, &o. 
When there is bleeding from the ear, it is a question whether 
syringing with disinfectants shouLl be carried out. I con- 
sider it impossible to obtain in this way a complete disinfec- 
tion of the ear, and that syringing is, moreover, attended 
with risk of carrying infection towards the meninges ; and 
recommend, therefore, merely a thorough cleansing of the 
external meatus, and the skin around, with the use of steri- 
lised cotton wool. 

Remembering that crushing of the brain is perhaps less 
directly a cause of death than the pressure of the ex- 
travasated blood which accompanies it, it is reasonable to 
recommend trephining in such cases, and of late years some 
most encouraging results have been obtained from this 
operation. 

Fractures of the skull unite in the usual way by bone, but 
with the formation of less callus ^ than is the case elsewhere, 
for the reasons that the parts are kept perfectly at rest in 
the case of the skull, and that its periosteum forms new 
bone with difficulty. Occasionally after fractures of the 
vault in young children a gap may be left in the bone, lead- 
ing to a meningocele. (See note on next page.) 

' Sabre wounds of the skull proved long ago that large fragments or 
flaps of bone raight unite well after their detachment. There is a remark- 
able series illustrating this in the Royal College of Surgeons' Museum 
(London), Nos. 862 to 868, the specimens forming which were doubtless 
obtained from soldiers who had served in the Napoleonic wars. Flaps of 
bone from two to three inches in diameter, which had been severed more or 
less completely from the rest of the skull, are here seen to have united 
firmly, although the wounds no doubt suppurated. The bony rounding of 
the edges is very marked in nearly all the specimens. Of late years 
surgeons have learnt that fragments of trephined bone may safely be 
l-eplaced after an operation, and that even a disc two inches in diameter 
may unite well with the cranial vault if replaced — that it is even safe to 
turn down a large bony flap four inches or more wide from the side of the 
cranium for exploratory purposes. All these facts were clearly taught by 
such -inuseu«! s^>e4::jmens of fracture .as have been j.n.e]ntioned. — J. H. 



34 CHAPTER II. 

In young children depressed fracture of the skull, whilst it can hardly 
be attended with splintering of the internal table, and whilst the depression, 
however considerable, is almost always obliterated in course of time, may 
yet have special dangers of its own. The dura mater may be torn, and the 
subarachnoid fluid escaping through the skull at the site "of the fracture 
gradually form a large tumour beneath the scalp. The aperture in such 
cases tends to enlarge, and the fluid-containing cavity may, owing to an 
injury to the cortex, come to communicate with the ventricles of the brain. 
It will be understood that this pulsating tumour may form without any 
wound of the scalp. It is a dangerous complication owing to the risk of 
meningitis (see valuable papers by Eickman Godlee, ' Path. Trans.,' 1885, 
p. 313; Clement Lucas, 'Guy's Hospital Eeports,' 1876, et seq.; and 
T. Smith, 'St. Bart.'s Hospital Reports,' 1885).— J. H. 



Fractuees of the Bones op 'J'he Face. 

The bones of the face are so accessible to exammation from 
the exterior or from the nasal and oral cavities that their 
fractures oifer hardly any difficulty in diagnosis^ and, although 
almost invariably compound, they are attended with little 
risk of infection or special complication. 

Fractures of the nasal bones and of the septum lead as a 
rule to marked deformity (traumatic saddle nose). This 
deformity can in recent cases be to some extent removed by 
elevation with forceps. Amongst the symptoms the san- 
guineous effusion under the mucous membrane, epistaxis, and 
occasionally emphysema of the skin of the face are to be 
noted. 

Fractures of the malar bone and of the upper jaw result 
from direct injury, very often from a kick with a horse's 
hoof, and are therefore frequently complicated with skin 
wounds. There is little difficulty in diagnosis, and the treat- 
ment consists mainly in re-position and fixation of any 
displaced portion of the alveolar margin. This is best 
effected with the aid of the dental surgeon, whereby loosened 
teeth may often be retained. I have succeeded in obtaining 
good union of such a displaced fragment by means of fixing 
it in place by a steel peg. Great attention must be paid to 
keeping the mouth clean by syringing with three per cent, 
.solution of boracic acid, and careful feeding with fluids. 



Tab. 16. 




Fig. 3 b 




tig-jo- 




Figkb 



MgMa^ 



Luh.Ansl.v. F, R.einhhold , Miiiirhni 



PLATE XYl. 

FRACTURES OF THE LOWER JAW. 

Fig. I. — Recent fracture in the body of the lower jaw, running 
obliquely vip to the region of the molar teeth. 

Fig. 2. — Fracture running obliquely through the body of the lower 
jaw, and through both condyles. This interesting form of fracture is 
cei'tainly the result of a very severe injury, sustained probably through 
a fall on the chin (compare with this Plate XII, fig. 3, and the remarks 
on the latter). 

Figs. 3 a, h. — From a case of fracture of the right condyle and neck 
of the lower jaw. The fragment broken off has been displaced down- 
wards and united in this position. 

Figs. 4, 4 a. — Hammond's wire splint for fractures of the lower jaw. 



FRACTURES OK THE LOW KR JAAV. 35 



Fractures of the Lower Jaw 

are more numerous than those of the upper. Their diagnosis 
is so easy, as arule, that little needs to be said about it. In 
fractures right through the horizontal ramus there is com- 
monly displacement downward;: of the anterior fragment, 
owing to the action of the digastric and the other muscles of 
the chin, whilst the other fragment is pressed upwards by 
the masseter, &c.' A certain amount of lateral displacement 
and overlapping is rarely absent, so that the arch of the 
lower jaw is diminished. Comminuted fractures are not un- 
common. The cause is nearly always direct violence, blows, 
kicks, shot wounds, &c., though indirect fracture may result 
from a fall on the chin or a violent force applied to the side 
of the bone. 

Treatment . — It must be remembered that fractures of the 
lower jaw are always compound, even when there is no 
wound of the skin. For this reason great pains must be taken 
in disinfecting the mouth, and where the gums are much torn 
the use of iodoform gauze is indicated until the wounds can 
be sewn up with appropriate sutures." The reduction of the 
displacement by direct pressure is as a rule easy, but to re- 
tain the fragments in good position is difficult owing to 
muscular action. Fortunately we are no longer confined to 
the use of splints and bandages which press the lower jaw 
against the upper one ; with the help of the dentist fixation 
can be secured by means of splints fastened to the teeth, on 
either side of the fracture, and sometimes the use of thin 
silver wire around the adjoining teeth will suffice. Where 
these measures are impracticable we may be compelled to em- 
ploy the old form of apparatus, or to drill the bone and fix the 

^ Two thh'ds of the fractures of the lower jaw occur in the horizontal 
ramus between the lateral incision and the second bicuspid. This is owing 
to the bone being here comparatively thin, and further weakened by the 
presence of the deep socket for the canine tooth. Fractures through the 
symphysis menti ai-e extremely rare, owing to the great density of the bone 
in this position. — J. H. 

^ It is very rarely, if ever, tliat sutures can be usefully applied to the 
torn mucous membrane of the gums. 



36 



GHAPTKK IT. 



fragments by stout silver wire. Fractures of the alveolar 
portion are common from rougli or unskilled attempts at 
tooth extraction/ especially from the use of the key. 

Fig. 23. Fig. 24. 




Fig. 23. — Displacement from muscular action following fractured 
lower jaw. 

Fig. 24. — Preparation of a fracture of the lower jaw, with lateral 
displacement. 

One of the rarer forms of fracture of the lower jaw is that 
of the condyle (see Plate XVI, figs. 2, 3 a, and 3 6) ; another 
is that of t he coronoid process, which may be torn off by the 
temporal muscle, the displaced fragment uniting by fibrous 
tissue with a wide interval, 

' These attempts are a fertile cause of necrosis of the jaw. In young 
children especially the extent of hone which may require removal is 
remarkable. Thus in tlie case of a child aged four a fracture from rough- 
ness in extracting a tooth led to necrosis of the ascending ramus. I 
removed tlie whole of this, including the coronoid process and the neck 
of the jaw, as one sequestrum. A complete case of new bone was being 
formed at the time, and in such cases the ultimate result as regards firmness 
in biting is surprising.— J. H. 



INJURIES 'I'O THE LOWER JAW AND LAUYNX. 37 



A. Dislocation of the Lower Jaw. 

Symmetrical dislocation forwards is fairly frequent, being 
produced in wide opening of the mouth (yawning, vomiting, 
&c.).^ It is well known that in ordinary opening of the 
mouth the condyle travels forwards beneath the articular 
eminence. The axis of this movement passes through the 




Fig. 25. — Action of the external pterygoid mnscle with regard to 
dislocation of the lower jaw. 

beginning of the inferior dental groove above the lingula on 
either side. If this movement is carried further the condyle 
rides over the eminence into the temporal fossa, where it is 
fixed by the contraction of the muscles, especially the tem- 
poral. This dislocation is more common in women than in 
men. 

The symptoms of the dislocation are simple enough ; — wide 
opening of the mouth, projection of the lower row of teeth 
in front of the upper, complete inability of the patient to 

' Dislocation of the jaw may occur during tlie manipulations of the 
dentist, and may be overlooked for a time. 



38 



CHAPTEE IL 



close the mouth herself^ absence of the condyle from its 
normal place and its presence further forwards.-^ 




Fig. 26. — Method of reducing a dislocation of the lower jaw. 
The operator's thumbs should be guarded. 

When the jaw is dislocated on one side only, the mouth 
is opened wide and the chin pushed over somewhat towards 
the sound side. 

The capsule of the joint is as a rule uninjured, but much 
stretched (see Plate XVII, fig. i). Children are not liable 
to this dislocation. 

The prognosis is favourable, but there is in some cases a 
marked tendency to recurrence of dislocation. To reduce it 
the lower jaw must first be pressed downwards and then 
backwards (this is best accomplished by means of the two 
thumbs pressing on the alveolar portion of the jaw). As 
the condyle slides over the articular eminence one feels a 
sudden cessation of the resistance which had been caused by 
muscular contraction or stretcliing. 

' Probably the pain felt is largely due to stretching of the lingual or tlie 
inferior dental nerve, and tiie increased flow of saliva may be due to the 
same cause. 



Tab. .17. 



V^ 




i^.y 





Fig. 3 



LitkSiist.v F.Reichhold, Miinchen 



PLATE XYII. 

DISLOCATION FORWARD OF THE LOWER JAW. 

Fig. I. — Symmetrical dislocation of tlie lower jaw produced experi- 
mentally on the dead subject. The mouth is wide open, the chin 
pushed forwards. The condyle of the lower jaw is placed in front of 
the eminentia articularis, behind which is seen the empty glenoid 
fossa ; the capsule of the joint has not been torn, but merely stretched. 
The temporal muscle is in a condition of great tension, owing to the 
forward displacement of the coronoid process, and therefore presses 
the condyle against the bone in front of the articular eminence. 

Fig. 2. — Normal relations of the articulation when the mouth is 
closed. 

Fig. 3. — The same when the mouth is opened; the condyle rests on 
the articular eminence. 



INJÜKIES TO THE MEOK. 39 



B. .Backward Dislocation of the Lower Jaw. 

This is an extreme rarity^ practically confined to women. 
In this form the condyle (owing to yawning, spasmodic 
muscular contraction, a fall, &c.) rides over the small tym- 
panic tubercle which borders the articulation behind, and 
reaches the fossa by the stylo-mastoid foramen, almost under 
the external auditory meatus. 

To effect reduction, pressure should be made on the lower 
jaw downwards and backwards, followed by movement to and 
fro ; or forcible opening of the mouth by means of a gag may 
succeed. 



[c. Fractures of the Hyoid Bone and Thyroid Cartilage. 

These are of sufficient interest to deserve a few words^ 
especially as there is a fallacy of diagnosis to be guarded 
against in connection with injuries to the neck. If the 
normal larynx is held between fingers and thumb and moved 
laterally over the cervical spine, a sort of crepitus is often 
felt. This symptom, should the patient have sustained any 
injury to the neck, may readily lead the surgeon to an 
erroneous diagnosis of fracture of the hyoid bone or thyroid 
cartilage. The mistake is of especial importance, since in 
such a case the patient is probably examined on account of 
some violence which may be the origin of a criminal charge. 
No one who has not tried the experiment mentioned would 
credit how deceptive the feeling of crepitus is. As a rule, 
fracture of the hyoid bone or thyroid cartilage is due to such 
force (whether the larynx is grasped by the hand of an 
assailant or struck by his fist, &c.) that marked evidence of 
external bruising accompanies it, and there is, moreover, much 
respiratory distress. Some hyoid bones, however, are so 
lightly made, and therefore fragile, that very slight violence 
might break them (this is especially the case in women). 
According to Dr. Gibb, in three out of fourteen cases of 



40 CHAPTEIi ir. 

fracture of the liyoid^ muscular action alone was the cause. 
Probably the most frequent site for the fracture is about the 
junction of the great cornu with the body of the hyoid^ and 
the fracture may be bilateral. Owing to the action of the 
middle constrictor union is almost sure to occur with the 
cornu bent inwards. It may be noted that the hyoid bone 
is often fractured in cases of hanging. 

Fracture of the thyroid cartilage is unlikely but not im- 
possible to occur before the cartilage has begun to ossify ; it 
is in any case a very serious injury^ owing to the accompany- 
ing shock and dyspnoea and the subsequent risk of oedema 
glottidis. Several cases of fracture of the tracheal rings 
have been recorded. — J. H.] 



FßACTÖRES AND DISLOCATIONS OF THK SpINE. 

Fractures of the vertebral bodies, of which those of the 
fifth and sixth cervical vertebrae and of the lowest dorsal 
and upper lumbar ones are the most frequent, occur as the 
result of great violence. ^Jliis great force is required owing 
to the extreme elasticity of the spine, which is due to the fact 
that one fourth of its length consists of intervertebral discs. 
How mobile the spinal column can become through practice 
is shown in the so-calJed " gutta-percha men/^ who are able 
to bend to a sharp angle the cervical and lumbar portions 
of their spinal column. It is at these two points that 
fractures are most commonly observed, since the compressing 
force acts here at its greatest advantage. It will be re- 
membered that when a force acts upon a column of varying 
elasticity it will break most easily where a more flexible joins 
a less flexible part ; and these conditions are present at the 
junction between the twelfth dorsal and first lumbar ver- 
tebree, and still more in the lower cervical region. 

Fractures of the vertebral bodies from direct violence are 
extremely rare, and even when the back is run over indirect 
violence as a cause of the fracture is not excluded. Fi-actures 
from indirect violence especially involve the bodies of the ver- 
tebrae, either by means of forcible flexion, or of compression, 
or of a force causing antero-posterior displacement. As a rule 



Tab. 18. 




LltluAiyi .V. F. Reifllihdld , München . 



PLATE XYIII. 

FEACTUKE OF THE SIXTH AND SEVENTH CERVICAL VEETEBE^ 
WITH CRUSHING OF THE SPINAL COED. 

The patient, a woman aged thirty-three, lived seven days after the 
accident, death being due to respiratory failure. During life there 
was sensory and motor paralysis of the trunk and lower limbs, with 
partial paralysis of the upper limbs. The upper limit of the sensory 
paralysis was at the level of the third rib. There was retention of 
urine. In the region of the sixth cervical spine there was marked 
projection. Under an anaesthetic this could be obliterated. The 
treatment consisted in the use of a water-bed, and of weight extension 
applied to the head. 

The illustration shows extremely well fracture of the two vertebral 
bodies and the projection of the seventh backwards, producing nar- 
rowing of the vertebral canal and ciaishing of the spinal cord. 



FßACTUHE-DISLOCA'riON OF THE SPINE. 41 

there is a combination of these factors. The accident may 
occur in a fall upon the back of the head, on to the pelvis, or 
the feet, sometimes from a heavy fall of earth, &c., upon the 
back, whilst at the moment of the accident the vertebral 
column as a whole is more or less rigid owing to muscular 
contraction. 

Different forms of fracture of the vertebral bodies may be 
distinguished : 

1 . Oblique fractures, the obliquity being generally from 
above downwards and forwards, with a marked tendency to 
antero-posterior displacement. These are the most common 
(see Plate XVIII). 

2. Longitudinal fractures, which are very rare. 

3 . Transverse fractures, which are caused by strong com- 
pression and forced flexion of the column, usually attended 
by impaction and consequent diminution of the vertical height 
of the bone. Although as a rule the outward appearance of 
the column in such cases may be but little altered, the verte- 
bral canal may be much narrowed, and the spinal cord 
crushed (see Plate XIX) . Detachment of fragments of bone 
and displacement of the intervertebral discs may be present 
as complications. 

8ympto7ns. — Apart from the condition of shock, which is 
so often present after such severe injuries, one of the most 
pronounced features is the kyphosis resulting from shortening 
of the front of the vertebral column, due to impaction or to 
antero-posterior displacement. 

Contraction of the powerful muscles of the spine and 
secondary movements may also have something to do with 
it. If the spine is fractured obliquely there may also be 
some lateral displacement. A slight degree of kyphosis is 
nevertheless hard to make out, and in many cases the only 
local sign may be a diminution of the normal lordosis, or 
hollowing of the spine. A well-marked pain at one spot is 
then a symptom of some value ; naturally there is no abnormal 
mobility, and crepitus is hardly ever to be obtained. 

When the spinal cord has been completely crushed we 
have paralysis of the lower and upper extremities (according 
to the site ol: the fracture), damage to the functions of 
bladder and rectum, sometimes a great rise of temperature 



42 OH APT KR II. 

if tlie lower cervical region lias been involved, and speedy 
death from respiratory failure. The reflexes are variously 
affected : as a rule when the cord has been crushed they are 
increased ; in slighter cases they may be unaltered/ or indeed 
increased. 

The diagnosis of a fracture of the vertebral bodies is self- 
evident in the really severe cases, in which there is kyphosis 
and symptoms of a complete transverse lesion of the spinal 
cord. It must, however, be remembered that in many cases 
of fracture of the vertebral bodies the spinal cord and the 
nerve roots escape injury. A glance at the fracture in the 
upper dorsal region shown on Plate XIX shows that the 
spinal cord here would not have been damaged. 

In such cases the force is less than usual, and the kyphosis 
or other visible deformity of the spine may be absent. Oc- 
casionally local pain produced by sudden pressure on the 
head may be of value in cases where the injury has occurred 
some little time before. 

The prognosis ot' these fractures depends on the extent of 
damage to the spinal cord. In itself the fracture of the 
vertebral bodies may readily unite with bone, and many 
patients survive after this injury, capable of working, so long 
as the spinal cord has not been damaged ; but if symptoms 
of the latter injury are present the case is always an anxious 
one. Even if myelitis does not supervene, other dangers 
threaten. The vesical paralysis necessitates the use of a 
catheter several times daily ; and although it is possible and 
imperative to carry this out with thorough aseptic precautions, 
only too often in practice it happens that cystitis from infec- 
tion by means of a catheter is produced, and that subsequent 
septic pyelo-nephritis gradually proves fatal. A second 
danger is produced by the anaesthesia of the paralysed parts ; 
not only may acute trophic disturbances, particularly after 
injury to the cervical part of the spinal cord, supervene, but 
from the simple absence of feeling in the skin, persistent 
pressure, especially where the skin is often moist, as in the 
sacral region, may lead to sores. No patients require more 
careful nursing, and constant oversight on the part of the 

1 Tin's is hardly correct. After complete crushing of the cord in all cases 
the knee reflexes, &c., are lost for at any rate a long period of tinie. — J. H. 




'ill-: V F!i;M.:hln;li!,MiiiMhm 



PLATE XIX. 

DOUBLE FKACTUKE WITH IMPACTION OF THE SPINAL COLUMN. 

The preparation was obtained from a slater, aged thirty, who fell, on 
the 28th May, 1894, from a roof about sixty feet above the ground. 
His back first struck the stony ground, and then his feet. He was 
unconscious for twenty-four hours. On admission there was pain in 
the upper and lower parts of the dorsal spine. There was no motor 
paralysis, but anaesthesia in the back of the thighs and the genital 
regions. After the second day there was incontinence of urine andfgeces. 
The case was complicated by an impacted fracture of the left os calcis, 
and a deep wound in the sole of the right foot. Later he developed 
bedsores and erysipelas, and one leg had to be amputated. He died on 
the 14th November, 1894, five months after the accident. The illus- 
tration shows the double impacted or compression fracture; the fifth 
dorsal vertebra is driven into the &ixth, together with the intervening 
fibro- cartilage, but the spinal canal is not materially narrowed (see 
fig. I a). The body of the first lumbar vertebra has been squeezed out 
of shape in all directions. The vertebral canal opposite to it is greatly 
narrowed, measuring only 4 mm. from before backwards, and the 
Cauda equina and their membranes were here adherent to the bone. 
The fracture has evidently occurred through forcible bending forward 
of the column. 



FRACTURES OP THIO SPINE. 



43 



surgeon^ than those with fracture of the spine with paralysis 
of a large part of the body. The use of a soft and smooth 
bed (water-pillow or water-bed), frequent slight changes of 
position, the greatest care in keeping the skin clean and dry 
and in preventing it from being soiled, and thorough anti- 
septic precautions in the use of a catheter are absolutely 
necessary. 







^ P5 pL, Uü 



The site of fracture does not always require special care. 
With fractures of the cervical region, weight ex1,ension 



44 



OHAPTEU II. 



applied to the liead (see Fig. 27) may be useful, though 
often the patient is more comfortable simply lying on his 
back, with the head and neck steadied by pillows. Fractures 
in the dorsal and lumbar regions of the spine can also, by 
means of a special apparatus, have weight extension applied 
to them. After a time a plaster-of-Paris jacket will be a 
useful support. 



Fig. 28. 



Fig. 29. 





Fig. 28. — Angular kyphosis in the region of the eighth or ninth 
dorsal vertebrae from a fall of five yards on to the hack. As soon 
as he became conscious the patient was able to walk with assistance 
to his home. Six days later he was admitted on account of pain in 
the region of tlie fracture. There were no other nervous sym- 
ptoms, and he made a good recovery. 

Fig. 29. — Same patient as shown in Fig. 29, with a Sayre's 
jacket applied. The latter somewhat conceals the deformity. The 
jacket would have to reach lower down and take a larger hold of 
the pelvis if the fracture were in the lower dorsal or lumbar 
region. 

Operations with the view of removing pressure from the 
spinal cord have been but rarely carried out, and quite excep- 
tionally have been of use. 



FRACTURES OF 'I'HE SPINE. 45 

Even in less severe cases^ in which damage to the spinal 
cord from crushing^ or blood extravasation^ or injury of the 
nerve-roots leaving the canal is not present^ the treatment 
must be carefully carried out^ since prolonged rest of the 
spinal column in a favourable position is necessary for con- 
solidation of the fracture, and the avoidance of secondary 
displacement at the site of the injury ; since the mechanical 
pressure of the spinal column in the upright position, and 
during' work, is an enormous one, and the production of new 
bone not very rapid or abundant. Hence an appropriate sup- 
port should be worn for long after the fracture. 



A. Fractures of the Vertebral Arches and Processes. 

These are not common, and may be divided into fractures 
of the spinous processes of the transverse or articular and of 
the laminae. They are illustrated in Figs. 30 to 32 ; and it 
may be noted, that a detached part of the bone maybe driven 
into the spinal canal. They usually complicate fractures of 
the vertebral bodies. 

[On the important question of operation by trephining the 
spine in cases of fracture-dislocation, Thorburn's conclusions 




Fig. 30. — Lumbar vertebra, fracture of the spinous process. 

may be quoted. His work on ' The Surgery of the Spinal 
Cord ' is a most valuable and complete treatise on the sub- 
ject. He sums up, " The operation of trephining the spine for 
traumatic lesions should l)e abandoned except in cases of 
injury to the cauda equina, since both tt, priori argument and 
the results of published cases show that it is unlikely to be 
of service." If the cord has sustained a complete transverse 
lesion, i. e. if it has been once completely crushed, so as to 




46 OHAPTBE IT. 

be transversely divided^ no operation can possibly lead to 
union of the two segments with recovery of function. Once 

Fig. 31. Fig. 32. 






\ . I 



Fig. 31. — Fifth cervical vertebra, fractured through its pedicle. 
Fig. 32. — Seventh cervical vertebra, with fracture of each 
lamina. 

divided tlie spinal cord is always divided. On the other 
hand, a fracture -dislocation at or below the first lumbar 
vertebra will involve the cauda equina, which may recover 
from severe contusion or even division^ exactly as other nerve- 
trunk s do. Out of the sixty-one cases Thorburn collected 
in which an operation was performed for fracture-dislocation 
of the spine, in only seven was there a bondßde improvement. 
In every one of these seven the lesion was at or below the 
last two dorsal or the first lumbar vertebrae. Limiting 
surgical interference then to the lumbar region of the spine, 
we must still further exclude those cases which are steadily 
regaining power. " I should be inclined to lay down the 
rough rule, that if at the end of six weeks there is no re- 
covery, or if recovery is at a standstill, then, and then only, 
should we operate for crushes of the cauda equina " (Thorburn, 
p. 162). 'i'he writer makes one exception to the above rule, 
viz. that early operation may be justified in cases where the 
vertebral arches have alone been fractured and driven on to 
the spinal cord ; these cases are, however, extremely rare. — 
J. H.] 



Tab. 20. 




Fig.lcL 



/ ' 'Wtfi>lMUi-<». 



Ijr 




Fi^.lh 




LithjbsiA'. Y. Retclihold , MiinrliPi\ 



PLATE XX. 

DISLOCATION OF THE CERVICAL VERTEBRA. 

These drawings are made from artificially produced dislocations. 

Figs. I a, h, show unilateral displacement of the fourth vertebra, the 
articular process of which projects in front of that of the fifth. The 
forward projection of the vertebral body on this side is shown in 
fig. I a. The adduction of the head to the right, and the deviation of 
the spinous processes, are seen in fig. i &. 

Pigs. 2 a, h. — Symmetrical dislocation of the fourth cervical vertebra 
forwards from forced flexion. 



INJURIES TO THE SPINE, ETC. 47 



B. Dislocation of the Spine. 

In the dorsal and lumbar regions pure dislocation is 
excessively rare ; in the cervical region it is of practical 
importance. One has to distinguish between dislocation due 
to forced flexion, and that due to rotation of the cervical 
spine. 

In the first variety the ligaments at the back are torn, 
and the vertebra above is displaced in front of the lower 
one (Plate XX, fig. 2). In the latter the dislocation is due 
to strong abduction towards the side which is not dislocated, 
together with a rotation forward of the vertebra above (see 
Plate XX, fig. i). The symptoms sometimes are perfectly 
characteristic : not only may the line of the spinous processes 
be interrupted, but the projection of the vertebral body may 
be felt through the mouth with the finger. The neck is 
always strongly bent forwards. This statement refers to 
the dislocation from forced flexion. In that due to rotation 
the head is turned towards the sound side, the difference in 
the line of spinous processes is much less marked. The 
spinal cord may be damaged, with the results already referred 
to ; the phrenic nerve will escape if the dislocation is below 
the fourth cervical vertebra. The prognosis depends upon 
the damage to the cord, &c., and the results of the attempt 
at reduction. We may specially note the dislocation of the 
occiput on the atlas from violent flexion or extension of the 
head, and of the atlas, both of them as a rule immediately 
fatal from the injury to the cord. 

The possibility of true dislocation in the region of the 
dorsal and lumbar vertebrae has been proved on the post- 
mortem table, but must be almost impossible to recognise in 
the living subject, i. e. it must be so difficult to exclude 
fracture. 

Treatment. — Reduction should be attempted, the patient 
being deeply aneesthetised. In the case of rotatory displace- 
ment the neck should be strongly adducted to the sound 
side, in order to overcome the locking of one articular process 



48 CHAPTER II. 

over the other ; when this has been effected the head is 
drawn backwards on the injured side. 

The manipulation must be made not entirely with the head, 
but also by means of the vertebree above the site of the dis- 
location. In the case of dislocation from flexion, first one 
and then the other side of the neck should be treated in the 
manner first mentioned. After reduction it is necessary to 
keep the neck fixed for some weeks in a suitable apparatus. 





Eig.lcL 



Kig.2 



M^i^SS^: 



Liih.Ar.si .V. F, RpinWinld . Miinrlii'r 



PLATE XXI. 

FRACTURES OF THE RIBS. 

Fig. I. — Preparation obtained from the body of a man aged fifty- 
tbree. The ribs from the third to the tenth are fractured in the 
axillary line, and the four lower ones are also broken about the angles. 

Fig. I a. — Horizontal section through the fourth rib, from the 
specimen figured above. The overlapping of the two fragments and 
their firm union are well seen. 

Fig. 2. — Recently united fracture of a rib without displacement, seen 
in horizontal section. The formation of callus is very obvious. 



CHAPTER III. 

FKAOTUEES AND DISLOCATIONS OF THE KIBS, ETC. 

Feactukes of tlie ribs constitute about 15 per cent, of all 
fractures^ but are extremely rare in children on account of 
the elasticity of their ribs. Naturally they are least often 
observed in the very moveable lowest ribs and the well- 
protected highest ones. The fracture may be due to direct 
or indirect violence^ whether the pressure be exerted from 
before backwards or fi-om side to side. 

The pleura and lung are often wounded by the sharp 
fragments^ and hence haemoptysis, hemothorax, pneumo- 
thorax, and perhaps wide-spread traumatic emphysema may 
result. The hemothorax may require puncture ; the emphy- 
sema is of no real gravity, as a rule disappearing in a few 
days. The treatment consists in the application of strapping 
and bandage to the chest, and attention to any complications 
that may arise. The union is bony, as a rule without much 
displacement. Fractures of the rib cartilages are not so 
rare as is perhaps supposed. They unite with but little, if 
any, bony callus ; they are chiefly met with in the case of the 
fifth to the eiglith ribs, the cartilages of which are the most 
exposed, and they are usually due to direct violence.^ 

1 It has been clearly proved that fractures of the ribs may originate from 
sudden contraction of such muscles as the latissimus dorsi or the serratus 
magnus. In old age, or in such general atrophy as may accompany dementia, 
the ribs often lose their natural elasticity, become charged with fat, and. 
very brittle. This is probably in some measure tlie explanation of the 
frequency of fractured ribs amongst the insane. But fracture from mus- 
cular action may occur in healthy strong adults ; in one such case I knew 
of, the accident occurred in the act of throwing a cricket ball. 

The use of strapping and bandage is sometimes best dispensed with, as 
they may increase the respiratory difficulties. If the dyspnoea throws a 

4 



50 CHAPTEU III. 



Dislocation of the Ribs. 

It is only necessary to mention this extremely rare injury, 
wliicli may occur either at the sternal or the vertebral end 
of the rib. 



FuACTURB OP THK StERNUM. 

This is due to direct violence, and is, as a rule, a very 
dangerous injury, on account of the internal viscera being 
frequently damaged at the same time. 

In a fall with the head bent forwards the impact of the 
chin may fracture the sternum, and under opposite conditions 
(hyper-extension of the back) the bone may also be broken. 
The diagnosis is not difficult on account of the superficial 
position of the bone, and also since displacement is usually 
met with.^ 

Treatment. — In two recent cases I was able to relieve the 
displacement by weight extension on the head j to maintain 
the reduction it was necessary to keep a firm pillow behind 
the thorax. 

serious strain on the right side of the heart, leading to cyanosis, venesection 
may be called for, though it will probably not be required in more than 
one out of fifty cases. — J. H. 

' Tlie same injury that leads to fracture of the spine or oE the ribs may 
break the sternum ; thus, out of nine cases of fractured sternum at St. 
George's Hospital, eight were complicated with fractured spine and six 
with fractured ribs (Holmes's 'System,' vol. i, p. 813). The diagnosis is 
not perhaps always so easy as the above statement would impljs and pro- 
bably many cases are overlooked. There is an interesting specimen of 
separation between the manubrium and gladiolus sterni in the London 
Hospital Museum which illustrates this. It was obtained from a woman 
who fell out of window when drunk, sustaining various injuries. At the 
end of a few weeks an abscess over the sternum had develo])ed, and when 
this was opened the fracture-dislocatiop was first recognised. She died of 
pyuemia seven weeks after the accident. The upper end of the sternum lay 
in an abscess cavity. — J. H. 



Fi^.1 



^"^^^^^ 




lj:ig.2 



Tab. 22. 




^^-^■^ 



rzg.ü 




Fig.k 



LithJlnrt.v. F. Reiohhold, München 



PLATE XXII. 

Fig. I. — Horizontal section of a fracture of a costal cartilage. The 
fragments are much, displaced, and bound together by scattered masses 
of bone. 

Fig. 2. — Horizontal section showing fracture of the fifth costal 
cartilage and adjoining bone, with fibrous union. 

Fig. 3. — Fracture of the body of the sternum produced artificially. 

Fig. 4. — Fracture of the stei'num united with overlapping. 



FRACTÜUliS OF THE CLAVICLE. 51 



Feactübes and Dislocations of the Upper Extkkmity. 

As a result of indirect violence to the upper extremity 
various lesions may follow; for instance^ from a fall on the 
hand the patient may sustain either a Colles^s fracture^ a 
dislocation of the elbow, of the shoulder, a fracture of the 
humerus, or (especially in children) a fracture of the clavicle. 

Fractures of the Clavicle 

form about 15 per cent, of all fractures, and the most 
common site is about the middle of the bone, or rather 
nearer its sternal end. They are usually due to indirect 
violence {e. g. a fall on the hand with the elbow and shoulder- 
joint rigid, or a fall on the shoulder). Since the clavicle 
rests on the first rib when the shoulder is fully depressed, it 
may give way across this bone as a fulcrum in carrying heavy 



Fig. 33. — Specimen of united fracture of the right clavicle, seen 
from above. Callus excessive ; the inner fragment is drawn 
upwards and forwards, and over-rides the outer one. 

weights, &c. Incomplete or greenstick fractures are espe- 
cially common in this position amongst children. The sym- 
ptoms of the usual form of fracture are very characteristic. 
Muscular action, as well as the weight of the arm, is of 
importance in producing the displacement. The sternal 
fragment tends to be drawn upwards by the cleido- mastoid 
muscle. The arm is drawn down and towards the chest by 
the strong muscles (pectorales, &c.), the action of which in 
this direction is normally opposed by the clavicle acting as a 
pillar from sternum to shoulder-blade. 

Besides the downward and inward displacement the arm 
and outer fragment undergo a rotation inwards. The treat- 
ment of this typical form of fracture can now, as a rule, be 
carried out, even in the worst cases, with success, in the 



52 



CHAPTJi:R II [, 



Fig. 34. — Fracture oE the riglit clavicle, united with upward and 
forward displacement of the inner fragment. The shortening of 
the right clavicle is obvious if a measurement be taken from the 
middle line of the sternum to the outer border of the shoulder. 



;>*.., 



Fig. 35. — Recent fracture of the right clavicle, with typical 
deformity, the long inner fragment projecting upwards, the 
outer fragment and shoulder depressed. 




Fig 36.— Puttii 



i[) a iractured clavicle ; the assistant draws back 
the shoulders. 



FRACTURES OF THE CLAVICLE. 58 

sense of overcoming the deformity. In old times this was 
regarded as almost impossible. During the application of 
the apparatus an assistant should stand behind the seated 
patientj and with both hands should draw the shoulders 
well backwards (aided perhaps by the assistant's knee). 
Sayre's method^ requiring three bands of strapping, is one 
of the best that can be used. The first strip is meant to 




J>' 



• -»•i!v«."«j!w*»<">"rtwi(,w<i"v>^^''i« 9?wwH» 



Fig. 37. — Tlie use of Sajre's method in putting up a fractured ''; 

clavicle. 

correct the inward rotation of the arm, passing round the 
arm from within outwards and so behind the back ; the 
second band raises the sunk arm, passing under the elbow 
and over the shoulder of the sound side ; the third strip 
supports the forearm and passes over the injured clavicle, 
exerting slight downward pressure on the inner fragment 
(see Fig. 37). An axillary pad of moderate size is used. 



54 



CHAPTEIi III. 



over whicli; in summer especially^ it is desirable to sprinkle 
some boracic and starcli powder. The whole is carefully- 
bandaged over, and the turns fixed together with stitches. 
To increase the action of the bands of strapping, pieces of 
india-rubber band may be inserted, as shown in Fig. 38, so 
as to exert constant traction. 



Fig. 38. 



Fig. 39. 




^^ 





Figs. 38 and 39. — The use of bands of strapping, with intercalated 
pieces of rubber webbing. 

Properly applied, and with due oversight of the patient, 
this method may be trusted to give excellent results in 
fractures of the clavicle, and it is to be regretted that so 
many indifferent ones are met ^^■ith. Amongst the compli- 
cations we have primary injury to the brachial plexus, or 
secondary trouble from pressure due to callus,^ or less com- 

' Sir Robert Peel died from fractured clavicle producing a woiind of the 
subclavian vein. 

The amount of callus produced after a fracture of the clavicle is some- 
times extravagant. I have seen more than one case in which it gave rise 
to the suspicion of tumour, and in the London Hospital Museum there is a 
specimen from a case in which the whole clavicle was actually excised for 
this reason. 

The patient from whom it was obtained presented himself as an out- 
patient at the London Hospital with a painful tumour on the right 




Tab. 23. 





lithJnst.v.F.Rficlüiold.Münchni. 



PLATE XXIII. 

FRACTURE OF THE CLAVICLE, WITH TYPICAL DISPLACEMENT. 

The site of fracture is at the junction of the inner and middle thirds 
of the bone. The inner fragment appears to be drawn upwards by the 
contraction of the cleido-mastoid muscle, or pushed in the same direc- 
tion by the outer fragment. The great pectoral muscle has been partly 
removed, and the axillai-y space (considerably narrowed by the dislo- 
cated head of the humerus) is thus exposed. The shoulder and arm are 
depressed. ■ 



KRACTUIJES OF THE CLAVICLE. 55 

monly injury to the subclavian vessels. Damage to tlie pleura 
or summit of the lung by a sharp fragment of the clavicle is 



Fio-. 40. — Right clavicle seen from behind. Oblique fracture 
through the sternal third firmly united by callus. 



Fig. 41. — United fracture of the acromial end of the right clavicle, 
seen from in front. The smaller fragment is directed obliquely 
upwards ; the two fragments impinge against each other like 
the rafters of a roof. 

excessively rare. Fracture of the acromial end of the clavicle 
is sometimes accompanied by marked displacement (see Fig. 
41), and may offer considerable difficulty in the treatment. 

clavicle. As he denied having met with an accident, he was at first treated 
on the supposition that it might be of syphilitic origin. There being no 
improvement he was admitted as an in-patient. Crepitus was discovered, 
and the possibility of ordinary fracture from violence having been excluded 
by the persistent statement of the patient, it was after consultation decided 
to remove the clavicle as probably the seat of malignant disease. The 
operation was performed by Mr. John Couper in 1886, and section of the 
bone disclosed the true character of the tumour. The man returned to the 
hospital in 1872, and had quite as good use of the right as of the left 
upper extremity. 

A similar excessive formation of callus around a simple fracture (without 
perhaps material displacement) has been known to occur in the case of 
other long bones, particularly the femur and tibia, and amputation of the 
limb has been resorted to in the belief that a steadily growing sarcoma was 
present. Only elaborate microscopical research can sometimes decide the 
question. 

l"'racture of the clavicle may fail to unite by bone; and the movements 
of the fragments may so irritate the cords of the brachial plexus as to 
produce a condition allied to writers' cramp on any attempt to use the 
hand. Mr. A. E. Barker has recorded a case of this in which the symptoms 
were completely relieved by wiring the fracture. — J. H. 



56 CHAPTEU. III. 

I 



Fio^. 42. — Recent fracture of the acromial end of the clavicle. 
The left normal clavicle measures 18 cm., the right one 16 cm., 
showing that the acromial fragment is only 2 cm. long. The 
latter projects strongly upwards, and is already united with the 
inner fragment, which is obliquely displaced upwards, and the 
end of which is easily felt under the skin. 



Dislocation of the Clavicle. 

The dislocation of the sternal end may be in one of three 
directions — forwards^ upwards, and backwards (see Plate 
XXIV). 

The diagnosis is always easy, since the palpation of the 
displaced bone end will prevent mistake with the sharper 
poiiit of the fractured bone, and it may be confirmed by 
measurement of the length. 

In the case of dislocation backwards, owing to pressure 
on the trachea and oesophagus, difficulty in breathing and 
swallowing maybe present. The re-position is usually easy, 
the retention in good position difficult. Bands of strapping 
exerting direct pressure on the replaced joint end should be 
used, combined with elastic traction, and under certain cir- 
cumstances with the addition of subcutaneous suture. 



Dislocation of the Acromial End. 

In exact language this should be termed dislocation of the 
scapula. The clavicle may be displaced upwards or down- 
wards, the latter being of extreme rarity. The former may 
Ije said to be compL te, when after rupture of the coraco- 
clavicular ligaments the scapula travels still more downwards. 
In the diagnosis, which is as a rule easy, care must be taken 



Tab. 24. 





«0 



FJg.1 




FiglcL 




lith Jtasi v. F. ReioWiold , München 



PLATE XXIV. 

DISLOCATION OF THE STEENAL END OF THE CLAVICLE. 

Fig. I. — View from in front of a man aged fifty-seven, with forward 
dislocation of the right clavicle at its inner end. The right shoulder 
is slightly approximated towards the middle line. 

rig. I a. — Dissection of the dislocation represented above. 

Fig. I h. — Backward dislocation of the clavicle, showing how the 
trachea and oesophagus might be severely compressed. 



Tab. 25. 




FAg.1 






FiglcL 



Fig.ib 



lithJnst.v'. F.Reichhold, München . 



PLATE XXV. 

UPWARD DISLOCATION OF THE ACROMIAL END OF THE CLAVICLE. 

The abnormal projection of tlie clavicle on the right side is at once 
evident, together with the depression of the head of the humerus 
and the acromion. The latter is still more plainly seen in fig. i b. 
Since the action of the clavicle, as a prop or pillar to the scapula, is 
lost, the arm falls inwards towards the chest, and the axillai'y cavity 
is diminished. 

Fig. I a illustrates this displacement on the skeleton. 



FRAOTüllES OF TH K SCAPULA. 57 

not to mistake the injury for dislocation of the liuiiierus or a 
fractured clavicle^ and exact measurement of the length of 
the clavicle and following the line of the acromion on each 
side with the fingers^ will prevent mistake. 

In the treatment the arm must he kept elevated, and the 
clavicle depressed by means of strapping and elastic bands, 
and perhaps subcutaneous suture of the ligaments.^ 

Fractures of the Scapula. 

These amount in all to only about one per cent, of frac- 
tures. Those of the body and spine of the scapula are 
due to direct violence, often take the form of multiple lines 
of fracture and fissures (see Plate XXVI), and crepitation and 
abnormal mobility can frequently be distinguished. The 
ti-eatment consists in keeping the afPected arm and shoulder 
at rest, and light pressure with a bandage. Fractures of the 
neck of the scapula inside the coracoid process, and some- 
times starting from the supra-scapular notch, although very 
rare, are of importance, since they may be mistaken for sub- 
coracoid dislocation of the humerns. 

A prominent symptom is sinking of the ai'm, which may 
be somewhat abducted, with projection of the acromion ; the 
deformity can, however, be made to disappear with upward 
pressure on the arm, when crepitus is felt, and it is repro- 
duced as soon as the pressure is taken off. Sometimes the 

■^ A few cases have been recorded in which the clavicle has been dis- 
located at both ends, the inner end forwards and downwards, the outer end 
backwards and upwards into the posterior triangle. The ligaments must 
be very extensively torn, since the bone is described as being directed 
almost at right angles to its normal position (see ' Brit. Med. Journ.,' 
Oct. 26th, 1896, and ' Gaz. des Hop.,' 1859). It may be noted that besides 
the two directions in which the author describes the acromial end as being 
displaced, viz. upwards and downwards, a direct backward dislocation 
appears sometimes to occur. Davis (' Annals of Surg.') describes a case 
and refers to several others. In any of the forms of dislocation at the 
acromio-clavicular joint, if much difficulty is found in retaining the bones 
in position, it may be justifiable to secure them together by wire suture. 
Poirier and others have recorded cases where this has been done with 
success ; and although it can be but rarely required, the method is mucli 
more likely to attain its end than the " subcutaneous suture of ligaments " 
referred to by Professor Helferich. — J. H. 



58 CHAPTER in. 

edge of tlie fracture can be felt tlirougli tlie axilla. In the 
treatment the arm must be kept elevated, and pressed some- 
what outwards and backwards, the whole arm and scapula 
being kept at rest b_y the use of Sayie^s method for the 
treatment of fractured clavicle. 



Fig. 43. — Detachment (partial) of part of the glenoid fossa. 

Fracture of the edge of the glenoid cavity (rare) produces 
slight sinking of the head of the humerus when the latter is 
abducted to the horizontal position, whilst crepitus may be 
felt on movement of the shoulder. Isolated fracture of the 
coracoid process (from direct violence) is excessively rare ; a 
similar fracture of tlie acromion more common. 



Dislocations of the Shoulder. 

'J'hese form some of the most frequent and important of 
all injuries ; their diagnosis is, as a rule, not difficult, but 
yet many cases escape recognition. On pjilpation of the 
normal shoulder one feels the projection of the aci'omion 
below, and to the inner side of it the coracoid process, the 
head of the humerus covered by the deltoid muscle, but yet 
so distinctly that the two tuberosities and the bicipital groove 
can be distinguished on rotation. Through the axilla the 
head of the humerus and the border of the glenoid fossa can 
be recognised. As is well known, the humerus is not held 
in position by the capsule so much as by muscular contrac- 
tion and by atmospheric pressure. In paralysis of the 
deltoid muscle the head of the humerus alwavs sinks down 



DISLOCATIONS OF THE SHOULD 1:R. 59 

somewhat^ and there »re cases of infantile paralysis of this 
muscle in which, fiom the thinness of the soft parts^ this 
depression of the bone can be at once seen. 



Forward Dislocation of the Humerus. 

This fornij either pre-glenoid, subcoracoid^ or sub- 
clavicular^ according to the degree of displacement of the 
humeral head^ is the commonest dislocation of the shoulder. 
On tbe dead subject it may be produced fairly easily by a 
gradual but vigorous backwnrd pressure of the much-ab- 
ducted arm ; by these means the capsule is strongly stretched 
over the head of the bone^ it gives way on the inner side, 
and the humerus passes through the rent under the coracoid 
process. When the arm is brought down the typical sym- 
ptoms of the dislocation are obvious (with the exception of 
the extravasation). On the living subject the dislocation 
occurs through direct pressure acting from behind and the 
outer side, more frequently from indirect violence from a 
fall on the hand, the elbow, or the ai'm, particularly when 
the latter is directed backwards. It may also be due to 
sudden muscular action in throwing, &c. In sti'ong abduc- 
tion of the arm the surgical neck of the bone of the humerus 
comes in contact with the acromion and upper edge of the 
glenoid fossa, which form a fulcrum, and the short arm of 
the lever is pressed out of its normal position. As a rule 
the dislocation is at first a subglenoid one, but from muscular 
action becomes almost at once subcoracoid. As regards 
the anatomical conditions, the head of the humerus rests 
directly on the inner border of the glenoid fossa ^ (see Fig. 

^ In most specimens obtained from cases of old unreduced dislocation of 
the humerus a more or less deep groove at the back of its head will be 
found. This groove in some cases is so sharply cut as to suggest the use of 
a chisel. It is probable that this grooving is present as a rule in the 
examples of recurring dislocation, and facilitates re-dislocation. The excava- 
tion is always due to wearing of the bone against the glenoid edge, though 
a slight indentation (which Mr. Caird has shown is of frequent occurrence 
in ordinary cases of subcoracoid dislocation) between the head and the 
great tuberosity may be due to a kind of impacted fracture at the time of 
injury. It is, however, quite a mistake to assert, as has been recently done, 
that this excavation is invariable in subcoracoid dislocation. In Sir Wm. 



60 



CHAPTRR III. 



44), In a subclavicular dislocation the head is moved still 
further inwards^ whereby the nxillary vessels and nerves are 
likely to be severely compressed. 




Fig. 44. — Horizontal section through the shoulder and thorax in a 
case of suhcoracoid dislocation on the right side. The normal 
position of the humeral head is indicated by a dotted line. The 
relation of the displaced liead to the axillary vessels and nerves 
is also shown. (After Anger.) 

The symptoms of a typical subcoracoid dislocation are 
very characteristic (see Plate XXVII), depending on the two 
facts that the head oP the bone is absent from its normal 
position, and present in an abnormal one. It is necessary 
always to begin with a careful inspection of both shoulders, 
and this alone is often sufficient for the diagnosis, so that 
palpation is only required to confirm this. The best position 
for the patient is to sit with both shoulders exposed, on a 
chair opposite to the surgeon, the arm on the sound side 
being placed in a corresponding position to that of the dis- 
located one. There is sinking of the shoulder, the acromion 
process forming a projecting angle. Below the coracoid 
process an abnormal projection can be seen and felt, and is 
made more distinct by attempting the rotation of the arm. 
The arm is slightly abducted, with strong pressure the 
elbow can be made to touch the side, but it springs out again 
directly the pressure is removed. This symptom is due to 

Flower's forty-one recorded dissections of old unreduced shoulder dislocations 
(' Path. Soc. Trans.,' 1861, p. iSy) in at least seven there was no groove 
whatever. — J. H. 



Tab. 26. 







Eig.1 



^x^y 



},.y > - 




Fig. 2 



Eig.2cL 



Litti.An si V. F Re ieWidld , ■Mimclim • 



PLATE XXVI. 

FRACTURES OF THE SCAPULA, 

Fig. I. — Dissection of fracture of tlie neck, the outer fragment 
including the glenoid fossa and coracoid process. 

Fig. I a represents this condition on the living subject ; the pro- 
jecting acromion and depression of the shoulder are well shown. 

Figs. 2 and 2 a. — Specimen of nmltiple fracture of the spine and body 
of the scapula. 



Tab. 27. 




'/'"'.i **\, . 




\ 



Lith Jnst.v. f. Reichhöld , München 



PLATE XXVII. 

SUBCORACOID DISLOCATION OF THE HUMERUS, 

From a man aged sixty-four, wlio liad sustained the injury three 
weeks previously. During this time the swelling had gone down, and 
the relation of the shoulder-joint had become easily recognised. The 
acromion projects markedly; the outer contour of the abducted arm 
shows an angle ; the axis of the arm is directed towards the coracoid 
process instead of towards the acromion ; there is fulness under the 
coracoid process ; the length of the arm appears to be increased. 



DISLOCATIONS OF THE SHOULDBli. 61 

tlie stretching of the coraco-humeral ligament and the 
muscles inserted into the tuberosities. The axis of the arm 




Fig. 45. — Subcoracoid dislocation of the right arm. The axis of 
the humerus on both sides is shown by a black line. 

is directed towards the coracoid process instead of towards 
the acromion. The outer border of the arm forms an angle 
at its centre (for explanation of this see Plate XXVIII) ^ the 
arm appears to be lengthened, and the actual measurement 
from the acromion to the external epicondyle is as a matter 
of fact often increased, at any rate never diminislied.^ The 
explanation of this fact lies in the position of the head some- 
what below its normal place in the glenoid fossa. The head 
of the bone can be more or less plainly felt through the 
axilla ; passive movements are limited and very painful, and 
active ones still more diminished. Amongst the complica- 
tions we may notice detachment of part of the great 
tuberosity, sometimes damage to t1ie brachial plexus, much 
more rarely to the axillary vessels. The nerve-trunks are 
always stretched, and sometimes squeezed between the side 
of the thoi'ax and the humeral head (see Plate XXIX) . The 

^ In comparing the length of an injured limb with that on the apparently 
sound side it must not be forgotten that the latter may Iiave been formerly 
injured. Thus, in a case under my observation, one of dislocation of the 
right humerus, there was apparently three quarters of an inch lengthening 
on this side, but the difference remained the same after reduction, and was 
found to be due to an old fracture of the left humerus. — J. H. 



62 



CHAPTER III. 



circumflex nerve is sometimes paralysed^ and on this account 
it is bestj after reduction of the dislocation^ to test tlie action 
of the deltoid in order not to make an error in the prog- 
nosis. 

Figs. 46 to 49 illustrate the differential diagnosis of sub- 
coracoid dislocation of the humerus. Jn each the letter a 
indicates the acromion. 



Fig. 46. 



Pig. 47. 





Fig. 48. 



Fig. 49. 





Fig. 46. — Upward di.slocation of tlie clavicle at its acromial end. 

Fig. 47. — Typical subcoracoid dislocation of the humerus. 

Fig. 48. — Fracture of the neck of the scapula, with flattening of 
the deltoid. 

Fig. 49.— Fracture of the neck of the humerus with abduction 
of the arm. 

Witli regard to the differential diagnosis we may note the 
following conditions which may be the cause of mistake, 
ist. Severe contusion of the shoulder. 
2nd. Dislocation upwards of the clavicle. In this the 



Tab. 28. 





Fig.1 



Fig.2 



LithJbuiy. F. Rekhhold , München . 



PLATE XXVIII. 

STJBCOKACOID DISLOCATION OF THE HUMBRTTS. 

Fig. I shows how the head of the bone lies deepei* than normal, and 
hence how the appearance of lengthening of the arm is produced. 

Fig. 2 shows the stretching of the middle fibres of the deltoid, the 
border of which forms an angle with the axis of the arm which 
has been already noticed— an angle open externally. 



Tab. 29. 




LitliJta>iy.F.R<?iehhold,Müntlim. 



PLATE XXIX. 

DISSECTION OF A SUBCORACOID DISLOCATION,; 

This plate shows a further stage in tbe dissection of the specimen 
figured, Plate XXVIII. The front part of the deltoid muscle has been 
separated from the clavicle and turned outwards, so „that the tense 
middle fibres of the muscle are seen from within. Part of the pectoralis 
major has been cut away, and the coracoid process is shown with the 
attachments of the pectoralis minor, coraco-brachialis, and short head 
of the biceps. 

Below the coracoid process the head of the humerus is shown with 
its cartilaginous surface projecting through a rent in the capsiile; the 
tense siipra-spinatus, infra-spinatus, and the teres minor are seen at 
their insertions. The axillary nerves lie immediately to £he inner side 
of the displaced head. ' : '* 

On the outer side of the surgical neck, between it and the deltoid, is 
a cavity which has been enlarged by the removal of fatty tissue, and 
through which runs the circumflex nerve. 



DISLOOATJONS OV THE SHOULDER. 63 

angular projection is formed by the extremity of the clavicle^ 
not of the acromion ; the arm is not abducted^ the deltoid is 
not flattened. 

3rd. Fi-acture of the neck of the scapula. In this condi- 
tion the acromion projects, the head of the humerus sinks 
downwards and somewhat inwards, but simple upward pres- 
sure of the arm removes the deformity, whilst crepitus is 
generally felt. 

4th. Paralysis of the deltoid muscle leads to sinking of 
the arm, which is less evident on upward pressure. The arm 
is not abducted. 





Fig. 50. — A simple apparatus for keeping the arm at rest after 
reduction of a dislocation of the humerus. 



5th. Fracture of the acromion with much displacement of 
the outer fragment j in this the relation between the acro- 
mion and the head of the bone remains unchanged. 

6th. Fracture of the neck of the humerus ; in this the 
projection of the humeral head is still present, even when 
the upper end of the shaft is displaced inwards and the arm 
abducted. The arm is never increased in length, but almost 
always shortened. 

Treatment. — The immediate re-position must be carried out. 
Often it succeeds without anaesthesia, though frequently the 



64 CHAPTKli 111. 

latter is required. Of the many different methods of reduction 
the following are here recommended : — (a) Extension of the 
slightly abducted arm by means of an assistant, whilst centra- 
extension is obtained by means of a broad towel passed round 
the chest ; the surgeon manipulates the head of the bone, 
pressing it in the direction of the glenoid fossa. 

(b) 8ir Astley Cooper's method, consisting in traction on 
the arm in the line of the trunk, with the foot serving as a 
fulcrum in the axilla, or (c) extension in the strongly abducted 
position of the arm whilst direct pressure is made on the 
head of the bone. 

(d) Kocher's Manipulation Method. — This consists in a 
series of movements which should be carefully and exactly 
followed (see Plate XXX). They follow each other, and 
consist in — 

ist. Adduction of the arm until the elbow touches the 
trunk. 

2nd. Rotation outwards with the elbow bent until marked 
resistance is felt (this must be done gently for fear of frac- 
ture) ; in this way the head of the humerus moves outwards 
from the coracoid towards the acromion process. 

3rd. The adducted and outward rotated arm is now drawn 
forwards and upwards ; the head begins to pass through the 
rent in the capsule and return to its normal place. 

4th. Inward rotation by which the head of the bone is 
completely replaced without any jerk, and so lightly that one 
often does not notice the moment of reduction, and first makes 
sure of this by examination. With this method reduction 
often succeeds without aneesthesia. During the adduction of 
the arm the upper part of the capsule is stretched and the 
head pressed against the glenoid edge, so that the later 
rotation turns it on the latter, and not round its own axis. 
When the arm is elevated the coraco-humeral ligament 
becomes relaxed. The success of the reduction makes itself 
known by a more or less evident click, and particularly by 
the return of the normal movement and contour. In the 
after-treatment the hand is kept over the sound shoulder by 
means of strapping or bandage. After eight days passive 
movements should be begun, a little later active ones. 'J'he 
total duration of the treatment up to the time when the 



Tab. 30. 



y^ 



<^^'- 





Fig.1 



Eig.2 




¥ü}.3 




Fig. if 



LithJinsi.v. Y Reiohhold, Müntlim 



PLATE XXX. 

ILLUSTRATING THE METHOD OF REDUCTION KNOWN AS KOCHER'S. 

In preparing these drawings the specimen shown in Plates XXYIII 
and XXIX was used, and photographs made at each stage of the 
reduction. 

Fig. I. — The arm is adducted until the elbow touches the side of the 
chest ; no marked difference is seen in the position of the head. 

Fig. 2. — The still adducted humerus is fully rotated outwards by 
means of the flexed foreai'm ; the rent in the capsule is more plainly 
seen ; the head is now nearer the acromion, and further from the 
brachial plexus. 

Fig. 3, — Whilst retaining the adduction and outward rotation, the 
arm is now fully elevated (brought forwards) ; and in fig. 4, by rotation 
inwards, the complete reduction is effected. 



DISLOCATIONS OP THE SHOULDER. 65 

patient can again resume work is about four to five weeks/ 
Should the reduction fail after repeated attempts under an 
aneesthetic, and in the hands of several surgeons_, an opera- 
tion, using the incision for resection of the head downwards 
from the coracoid process, is indicated. If the reduction is 
given up, as a rule a disastrous state of affairs remains, for 
it is only seldom that a new joint with fair mobility results ; 
as a rule the shoulder remains painful, and its mobility re- 
duced to a minimum. In these old cases improvement may 
be obtained by an open incision, and reduction after division 
of the obstructing bands of capsule, &c., or resection of the 
head of the bone. In rare cases the condition of recurring 
dislocation^ is produced. 

' Sometimes it is difficult to say whether delay in reduction or prolonged 
binding the arm to the side is most to blame for the deplorable loss of 
power in the arm which follows. To give an instance : a sailor aged fifty- 
five, with previous good health and no rheumatic history, sustained a 
subcoracoid dislocation of his right humerus. Being at sea at the time he 
was unable to get surgical treatment for two days, during which time he 
suffered much pain down the arm from pressure on the brachial plexus. 
At the end of the two days the dislocation was reduced, and for five weeks 
the arm was bandaged closely to the side. From this time to when I saw 
him (eight weeks after the accident) the arm was helpless. The musculo- 
cutaneous of all the nerves of the plexus had escaped best, the biceps and 
brachialis anticus action being fair. Deltoid action almost nil, extension of 
elbow very feeble, flexion and extension of both wrist and fingers extremely 
impaired. He was, for instance, quite unable to lift anything with the 
right hand, had to feed himself with the left hand entirely. The fingers 
were kept stiff in the slightly flexed position. Passive motion of the 
shoulder and elbow was much limited and painful. There was no proof of 
any neuritis, but ansesthesia of hand and forearm, although incomplete, 
was still marked (at the end of the eight weeks). 

In another case, an elderly man, the right shoulder was dislocated and 
reduced at a hospital, the arm being kept in to the side for five weeks. 
Complete atrophy of the deltoid muscle followed, with permanent ansesthesia 
over the lower half of that muscle (this was not quite complete). He 
attended the hospital for eighteen months, having galvanism and massage, 
but no real improvement resulted. 

In a third case, a woman who came to me about a year after the accident, 
the right arm remained stiff, painful, and almost helpless from the results 
of pressure on the brachial plexus. After the accident had happened (in the 
country) a doctor was called in, but he postponed the reduction for twenty- 
four hours in order to arrange for an anaesthetist being present. In this 
twenhj-four hours the mischief was done. — 3. H. 

2 Recurring dislocation of the humerus. — Recurring dislocation of the 

5 



66 OHAPTEII IIJ. 

Modifications and Gom'plications . 

If the head leaves the joint cavity directly forwards it lies 
between the scapula and the subscapularis muscle, so close 
to the glenoid fossa that its edge touches the articular carti- 
lage ; in these cases, which especially result from direct vio- 
lence, within a few weeks the opposed bone surfaces become 
reciprocally worn down, and this goes on increasing, so that 
a deep groove is produced in the head of the humerus, whilst 
the front portion of the glenoid cavity disa.ppears and a new 
articulation is formed. Reduction in such cases is very diffi- 
cult, and may be impossible without arthrotomy.^ 

humerus may take place although the head of the bone does not come through 
any rent in the capsule, and one of the following three conditions will then 
probably be present to produce it : 

1. Fracture of the anterior edge of the glenoid fossa, which if it unites 
by bone does so in a displaced position, so as to render the glenoid cavity 
narrower and more shelving. 

2. Separation of the capsule and periosteum in one piece from the neck of 
the scapula. This has. been clearly demonstrated by French writers (see 
Duplay and Reel as, ' Traite de Chirurgie '). The edge of the glenoid fossa 
then gi'adually wears down as the dislocation recurs, until at last it may be 
difficult to prevent the humerus from continually slipping out. 

3. Fracture of the coracoid process, when the symptoms of dislocation 
with crepitus on' reduction, which is effected by slight pressure only, are 
present (see report of case and dissection by J. F. South, 'Med.-Chir. 
Trans.,' vol. xxii, p. 100). — J. H. 

^ How long after the accident may reduction of the dislocation be safely 
attempted? It is really impossible to lay down a binding rule on this 
point. There are- two chief dangers to be thought of in old-standing cases. 
Efforts at reduction (and especially those involving strong abduction of the 
arm from the trunk, sudden jerky movements of tlie arm in manipulation, 
&c.) may cause fracture of the huinerus or rupture of one or more of the 
axillary, vessels. There are other minor dangers, such as the production of 
extensive bruising, tear of muscles, and possibly exciting the changes of 
osteo-arthritis. The older the subject the greater the chance that the 
vessels, if not atheromatous, will have lost their normal elasticity, and 
therefore be more liable to rupture. That the surgical neck or shaft of the 
humerus ma}' give way is also more likely in advanced life. Hence, if the 
patient is past the prime of life, the surgeon must be the less inclined to 
advise reduction even within reasonable lapse of time since the dislocation, 
i. e. from four to six weeks. It is true that breaking down adhesions by 
moderate manipulation may improve the range of movement, even though 
reduction be not effected ; but if tlie humerus is broken in forcible endea- 



Tab 31. 





Eig.i 





LilhAist.v. F. Rfinhlinlil . Miiiittien . 



PLATE XXXI. 

OLD SUBCOEACOID DISLOCATION. FORMATION OF A NEW GLENOID 
CAVITY. WEARING AWAY OP THE HEAD OF THE HUMERUS. 

(Compare the horizontal section in Fig. 44.) 

Fig. I shows the two bones seen from in front. The head of the 
humerus conceals the glenoid fossa, and articulates with the neck of 
the scapula immediately below the coracoid process, where there is a 
ridge of new bone formed. The humerus remains somewhat abducted, 
and the mobility of the new joint is extremely slight. 

Fig. 2.- — ^The same specimen, showing the back of the humeral head 
worn away. The eburnation of both bones which was present cannot 
imfortunately be seen in the illustration. 



Tab. 32. 



/ 




mg.1 



LithJnst v. F. ReichhoM , Müncheii . 



PLATE XXXII. 

FEACTUEE OF THE SUEGICAL NECK OF THE HtTMEETJS. 

Fig. I. — A dissection in wliicli parts of the deltoid and pectoralis 
major and minor have been removed in order to expose the fractured 
bone, &c. It will be seen that the shaft is displaced inwards, and 
endangers by its projection the axillary vessels and nerves. The long 
head of the biceps is twisted and displaced. 

Fig. 2. — An old severe fracture of the surgical neck, which implicated 
also the tuberosities and the anatomical neck. The upper end of the 
shaft is displaced upwards and inwards, and is united to the rest of 
the bone by much spongy callus. 



DISLOCATIONS OF THE SHOULDER. 67 

Supra-coracoid dislocation^ extremely i-are^ is always associ- 
ated with fracture of the coracoid process. Dislocation with 

vours at replacement (and this certainly happens much more often than one 
would suppose from printed records) the patient is left considerably worse 
than before, whilst if the axillary vessels be torn the danger to life is some- 
thing like 70 per cent. Great difficulty may be found in effecting reduction 
at the end of even three or four weeks, whilst it is rarely possible without 
incision after six to eight weeks bave elapsed. But this is only a general 
statement, and some remarkable exceptions where reduction has been 
secured at the end of four to six months have been put on record. Taking, 
then, six to eight weeks as being roughly the limit at which the surgeon's 
efforts (without operation) are likely to be successful, we may again 
emphasise the necessity for avoiding sudden and forcible abduction on 
account of the risk both to the bone and to the axillary vessels. 

The patient being fully anaesthetised the arm should be worked gently in 
all directions in order to break down adhesions, and then Kocher's method 
and traction with the arm moderately abducted should be alternately tried. 

Malgaigne, Körte, Callender, and Stimson have collected series of cases 
in which the axillary artery or vein, or the subscapular or other large branch 
of the axillary artery, have been damaged during efforts at reduction, and 
with the proviso that in a few of these the damage may have been done at 
the time of the dislocation, we have upwards of fifty cases from which to 
draw conclusions. 

1. Whilst some of the patients were old (in Sands' case eighty-four 
years, in Callender's sixty-one, in Hailey's fifty-nine), nevertheless a con- 
siderable portion were subjects under thirty, whose vessels must have been 
perfectly healthy. 

2. The axillary artery is far more likely to be torn than the vein, though 
the absence or cessation of pulsation in the axillary swelling, which first 
draws attention to the injury, is not conclusive evidence as to the implica- 
tion of the artery. 

3. Spontaneous cure is possible, but would seem to have occurred in only 
six out of thirty-two cases. 

4. Should this unfortunate accident occur, the best treatment would 
appear to be immediate ligature of the third part of the subclavian artery, 
unless there is strong reason to think that it is the vein or a branch of the 
artery only that is involved. To make an incision into the axilla, to clear 
out the blood, and to find and tie the bleeding vessel in situ would appear 
theoretically to be the right course, but it has the grave drawback that all 
the recorded cases have been fatal (see valuable paper by Lord Lister, 
' Brit. Med. Journ.,' January 4th, 1890, which gives the results of two cases 
of old dislocation operated on by open incision, division of adhesions, &c.). 
In his fatal case of rupture of the axillary artery (dislocation unreduced for 
eight weeks) it was found at the post-mortem that the artery had been fixed 
to the coracoid process and to the head of the humerus by a firm fibrous 
band of new formation. Many surgeons have recorded successful cases of 



68 



CHAPTER III. 



simultaneous fracture of tlie neck of the humerus is a very- 
severe injury. If reduction fails with the aid of direct 
manipulation an incision should be niade^ and if the loose 
fragment is small and chiefly intra-articular^ it should be 
removed. Formerly it was advised to make a false joint at 
the side of fracture, whilst leaving the head in its displaced 
position, 

Downivard Dislocation of the Humerus. 

In this form the head rests on the lower border of the 
glenoid fossa^ and is easily felt from the axilla; the arm is 




Y'lo-, ^i. — Horizontal section showing a subspinous dislocation of 
the humerus (compare Pig. 44). 



raised nearly horizontally from the side, the deltoid is 
markedly flattened, the acromion projects, the glenoid fossa 
is empty, and the functions of the joint are lost. Sometimes 
the arm is strongly elevated (Luxatio erecta), reduction suc- 

operation on old unreduced subcoracoid dislocation. With regard to this 
procedure it may be noted that — ist. Even with free exposure o£ the part 
by the ordinary excision wound it may be very difficult to make out the 
exact obstacle to reduction, and to divide it. The use of j)ulleys may be of 
great assistance. 2nd. Excision of the head of the bone sometimes gives 
the best result, especially when the dislocation is of very old standing. 3rd, 
No such operation is justifiable unless the patient is otherwise in thoroughly 
good condition, and unless there is no prospect of a fair range of mobility 
and usefulness of the arm being recovered. — J. H. 



FRACTURES OF THE HUMERUS. 69 

ceeds with traction on tlie arm_, and direct pressure on the 
head from the axilla. 

Backward dislocation (subacromial or subspinous) is very 
rarOj and occurs chiefly from direct violence. The head of 
the bone is readily seen and felt in its abnormal position ; 
the coracoid process projects in front.-^ 

Reduction is effected by traction on the arm when abducted^ 
and direct pressure. 



Fractures of the Humerus. 

A. Fractures of the upper end. — The bone may break 
through the anatomical or surgical neck, but more commonly 
the line of fracture does not exactly follow either. Direct 
violence may produce it from a blow or fall on the outer 
side of the shoulder, or the fracture may be indirect owing 
to a fall on the elbow pressing the head of the bone against 
the glenoid fossa or acromial vault. The diagnosis of these 
fractures is always difficult, and when there is much extrava- 
sation it is extremely so. Besides carefully noting the direc- 
tion of the humeral shaft, and any alteration in the contour 
of the shoulder, careful digital examination should be made, 
both from the outer side and from the axilla. Normally 
the tuberosities, the bicipital groove, and the surgical neck, 
are easily to be felt, not however the anatomical neck or 
the cartilage- covered head. Fracture through the ana- 
tomical neck, strictly speaking, is very rare. If the articular 
part of the head were alone broken off wholly within the 
capsule its vitality would be in question ; it might be com- 
pared to a loose body detached by violence in the knee-joint. 
As a rule this fracture is, however, not purely intra-capsular ; 
the fragment is nourished through bands of capsule, and 
the line of fracture runs through the adjoining tuberosities 
or upper end of the shaft. Impaction may easily happen, 

' In the case of an epileptic patient the humerus was displaced under the 
spine of the scapula during a fit. In spite of the conspicuous deformity no 
attempt at reduction had heen made, and when the patient came under obser- 
vation six months later the arm was much wasted even to the fingers, and 
was almost useless. There was nearly three quarters of an inch lengthening 
of the arm, which was practically rigid at the shoulder. — J. H. 



70 



CHAPTER III. 



tlie displacement is as a rule but sliglit^ but the loose frag- 
ment has been known to be turned completely round, so that 
its cartilaginous surface faced the shaft. 



Fig. 52. 



Fig. 53. 





Fig. 52. — Fracture of the great tuberosity of the right humerus. 
Fig. 53. — The upper end of the humerus, showing possible lines 
of fracture. 




/-<«(. 



Fig. 54. — Axillary pad made out of wood-wool encased in gauze, and 
retained in position by a bandage. 

The sym]3toms are those of a severe traumatic lesion of 
the shoulder-joint. Only under an anaesthetic can the 
fracture be made out, owing to abnormal mobility and 
crepitus. There will, of course, be marked loss of function 
and pain. 

Treatment. — With the patient in bed, weight extension is 
applied to the arm ; subsequently an axillary pad is used, and 
passive motion is commenced early. 



FRACTURES OP THbl HUMERUS. 



71 



B. Fracture through the surgical neck (see Plate XXX III, 
fig. 2) is a fairly common injury. The bone breaks below 
the tuberosities, or the shaft is impacted into the latter. The 




^'g- 55.— Separation of the left upper epiphysis of the humerus 
in a girl aged fifteen, who had fallen directly on to the shoulder 
from a considerable height fourteen days before admission to 
the hospital. The upper end of the diaphysis is displaced for- 
wards and inwards, and its axis directed in front of the aero- 




Fig. 56. — Shows the thickening on the pectoral aspect due to the 
displacement of the diaphysis. An incision was made on the 
front of the joint (as for resection) ; the diaphysis, which was 
completely displaced, was returned into position, and fixed by 
means of a steel needle. Union resulted with good movement 
in the shoulder. 



72 CHAPTER IIT. 

fracture is usually due to direct violence from a fall on to 
tlie shoulder, but occasionally from one on to the elbow or 
hand. The upper fragment remains partly under the influ- 
ence of the muscles inserted into the tuberosities. It is of 
importance alike for the diagnosis and the treatment to make 
out whether the shaft is driven inwards or outwards. In 
one case the axis of the humerus is directed towards the 
coracoid process or the clavicle, in the other the arm is 
adducted. The first is much the more frequent. When 

Fig. 57. Fig. 58. 





Fig- 57- — Fracture of the surgical neck. Tlie shaft is displaced 
inwards and abducted. 

Fig. 58. — Fracture of the surgical neck. The shaft is displaced 
outwards and driven into the head. 

this has occurred the arm is, as a rule, sliortened and slightly 
abducted. There is abnormal mobility as a rule if the head 
of the bone be well fixed, and if there is much displacement 
the upper end of the shaft may be felt under the pectoralis 
major and skin. It must be remembered that a dislocation 
may be combined with the fracture. 

Treatment. — Careful reduction of the displacement under 
an antesthetic is indicated; and weight extension, either with 
the patient in bed or going about (see Figs. 60, 61, and 62), 
should be employed. 

Counter-extension is advisable ; an axillary pad may, as a 
rule, be dispensed with. Careful passive motion should be 
begun as soon as possible. Fracture through the tuberosities 
is, as a rule, due to a fall or blow on the outer side of the 



Tab. 33. 




F4^.3 








Fig. ^a 



Fi^.k 



Liih.Ansr.v. F. Reinhliold , Münctieu . 



PLATE XXXIII. 

FEACTUKES OF THE UPPER END OF THE HUMERUS. 

rig. I. — Vertical section of a normal bone from a young adnlt, 
showing the epiphysial line. 

Fig. 2. — Separation of the ripper epiphysis; the specimen is seen 
from behind and the outer side. The diaphysis is displaced forwards 
and inwards. {Translator-' s note. — It is obvious that this is a mistake 
in description, since the line of fracture in no part follows that of the 
epiphysial junction.) 

Fig- 3. — Specimen showing an old united fracture, the upper frag- 
ment being somewhat abducted and the shaft adducted, so that the 
two are united at a right angle. There was probably some impaction, 
and there is much callus formed. 

Fig. 4. — Oase of fracture through the surgical neck in a man aged 
twenty-two. The shaft is displaced forwards and inwards, as will be 
seen by comparison of its axis with that of a normal humerus shown 
in fig. 4 a. 



FRACTURES OF THE HUMERUS. 



73 



shoulder. Impaction may be present. Tlie treatment is 
on the same principles as for fracture of the surgical neck. 



J? \ 



rig. 59. — Fracture of the surgical neck on the right side. The 
skin is puckered owing to the pointed end of the shaft. The 
arm is abducted and shortened. The patient was aged twenty. 
Complete reposition was effected under an anaesthetic. 

C. Traumatic separation of the upper epiphysis of the 
humerus (see Plates XXXIII and XXXIY). — This injury on 
account of its comparative frequency is of practical import- 
ance, and may be due to a fall^ either on the shoulder or the 
arm. The symptoms of this lesion are often quite charac- 
teristic ; the head of the bone remains in position^ and the 




Fig. 60. — Weight extension applied to the arm with counter- 
extension to the thorax, lateral traction being made also on the 
uppei- arm by means of a weight. 



74 



CHAPTER HI. 



slioulder is therefore not flattened ; tlie end of the diaphysis 
may project forwards and inwards^ presenting a circumscribed 




Fi^. 6i. — Weight extension applied with the elbow bent. 




Fig. 62. — Weight extension applied in a case of fracture of the 
neck of the humerus whilst the patient gets about. 

almost angular prominence, noticeable when one looks at the 
patient from the side or from above (see Figs. 55 and 56). 
Abnormal mobility, and perhaps a soft (cartilaginous) crepitus 
may be noticed on reduction. The latter may be found ex- 



Tab. 34. 




Eig.2 



Liili.Ansi.v. F ReicWiold , Müncliro 



PLATE XXXIV. 

SEPAEATION OF THE UPPEK EPIPHYSIS OP THE HUMERUS. 

Fig. I. — Dissection showing tlie epiphysis still retained in place by 
the capsule, &c. The end of the diaphysis is quite free, whilst bands 
of periosteum are seen attached to the epiphysis. The coracoid pro- 
cess is not yet united by bone to the scapula. 

Fig. 2. — Great impairment of growth in the right humerus from, an 
injury sustained in very early life. 



FRAOTUR.KS OF THE HUMERUS. 75 

tremely, difficult, or even impossible. If reduction is effected 
the treatment is tlie same as that for fracture of the surgical 
neck ; if reduction fails under an anaesthetic an incision 
should be made, and the interposed soft parts, periosteum, 
&c., disengaged, and the diaphysis thus returned into place. 
I have known of several cases of this kind in which after 
reduction a long steel needle was used for fixation with the 
best results. If incomplete replacement is obtained probably 
the growth of the bone will be much interfered with, and it 
is therefore most important to overcome the displacement. 
Weight extension and a good axillary pad may be useful 
after reduction. 

We sometimes observe detachment of this epiphysis in 
newly born children, resulting from injury at the time of 
birth ; in such cases the upper epiphysis (head and tuber- 
osities) may be strongly rotated outwards, whilst the dia- 
physis is rotated inwards. If this condition is not corrected 
marked loss of mobility will follow.^ 

' Analysing the records of sixty-six cases of separation of this epiphysis 
(thirteen of which were under my own observation), I find six occurring at 
birth and four during the first year of life. Omitting these, the average 
age at which the detachment occurred was thirteen years ; in no fewer than 
seventeen was the patient fifteen years old or more. Sufficient evidence 
exists from post-mortem examination or operation (in all eleven cases) to 
enable us to say that the separation occurs in probably nearly all of 
the cases exactly at the epiphysial line. The strong curve of the latter, 
due to the upward projection of the top of the diaphysis about its centre, 
is of practical interest. An American surgeon named Moore claimed that 
when the diaphysis is displaced it hitches (so to speak) against the outer 
and under part of the epiphysis ; hence the difficulty in reduction, 
to be met by a manoeuvre dignified by the name of " Moore's method," 
which simply consists in carrying the humerus forwards and upwards, then 
making slight extension whilst the arm is brought down to the side, and 
there fixed. Moore regards this locking of diaphysis and epiphysis as of 
constant occurrence, and that " no plan of treatment " (except his own) " is 
likely to succeed." The whole contention is a fallacy. In the case of dis- 
placement of the diaphysis, here, as in other parts of the body, the main 
difficulty in redu(^tion, if any exists, is due chiefly to interposition of soft 
parts, and especially of the tense periosteal sheath, through which the ex- 
panding end of the diaphysis has been driven. 

The following are the chief points in the diagnosis of separation of this 
epiphysis : 

I. The age of the patient — under about twent}' years. 



76 CHAPTER III. 

D. Isolated fracture of one or other tuberosity. — That of 
the great tuberosity is sometimes observed as a complication 

2. The arm is comparatively helpless, the elbow often directed a little out- 
wards or backwards. 

3. Abnormal mobility just below the shoulder-joint, best made out by 
abducting the humerus. 

4. Rapid swelling about the shoulder ; some shortening if the diaphysis 
is wholly displaced. 

5. Muffled crepitus on replacement. 

Dislocation was wrongly diagnosed in at least ^o per cent, of the re- 
corded cases ; a thorough examination under an anaesthetic is important. If 
once brought fairly back under the epiphysis the sinuous nature of the junc- 
tion will tend to keep the diaphysis in place. Steady traction on the arm, 
slight abduction, aided by rotary movement or by direct pressure, is the most 
likely to attain this end. There is probably no harm in trying "Moore's 
method," provided that no violent jerking movement is allowed. What 
should be done if the diaphysis protrudes just under the skin, and prolonged 
efforts at reduction fail ? Here (with every precaution as to asepsis), as the 
author recommends, the end of the diaphysis should be exposed, the opening 
in the periosteal sheath enlarged, or the rent in the other soft tissues held 
open and the bone returned to place. This has been done with success even 
at an interval of several weeks from the accident, but it is then usually 
necessary to resect part of the diaphysis. The same course should be fol- 
lowed in the cases of compound separation, where the diaphysis protrudes 
through the skin. In five such cases resection of the diaphysial end was 
performed and the bone returned to place, all ultimately recovering with a 
very useful arm. In two reduction was obtained without resection, but in 
one of these two inches of the bone subsequently necrosed. 

Amongst the rarer complications we have to note injurious pressure on the 
axillary artery or plexus of nerves, the former in two cases — Clark's and 
Hamilton's — having caused gangrene of the whole arm. Suppuration is 
exceptional in the non-compound cases, and shoxild rarely occur after reduc- 
tion of the compound ones ; but it has more than once led to the death of 
the patient. Noting also that bony ankylosis of the shoulder, from some 
cause difficult to explain, followed in four of my collected cases — in one sup- 
puration had occurred — we come finally to the important question of arrest 
of growth in the humerus, and even in the whole arm (with or without 
paralysis), following detachment of this epiphysis. Striking examples have 
been published by Bryant, P. Vogt, Bruns, and Humphry. In this case, as 
in practically every one where the arm has been more or less paralysed and 
non-developed, tlie accident which was to blame occurred at a very early age. 
Whether the brachial plexus is torn as well as pressed on by the displaced 
diaphysis in these cases we cannot at present decide. 

The necessity for thorough examination, correct diagnosis, and gentleness 
in manipulation in every case of detachment of this epiphysis must be 
emphasised. Nothing will so certainly be followed by arrest of growth as 



FRAOTUßES OF THE HUMERUS. 77 

of dislocation of the shoulder^ and may even result from 
efforts at reduction^ involving strong rotation. Fracture of 
tlie lesser tuberosity is much more rare. The symptoms are 
pain on pressure^ loss of f unction^ and a gap at the seat of 
fracture. The treatment consists in keeping the arm at rest 
with the fragments as nearly in apposition as possible. 

E. Fractures of the shaft of the humerus (Plate XXXV). — 
These may result from direct or indirect violence^ and 
present, in the most obvious way^ the usual symptoms — 
abnormal mobility, crepitus, and displacement of varying 
degree. If the fracture be below the insertion of the deltoid 
muscle the upper fragment will tend to be drawn outwards ; 
if towards the junction of the lower and middle thirds the 

roughly rubbing the fragments together, even if reduction is effected, and 
so destroying the delicate epiphysial disc of cartilage. 

A very important question arises as to how far an operation is justifiable 
in a case where the diaphysis has remained partly or wholly displaced, and 
the patient comes under care some weeks or months after the accident. 
What bad results have we to expect if nothing is done? First, arrest of 
growth, since the epiphysial disc almost certainly remains with the epiphysis. 
But the nearer the subject approaches adult age the less need we think of 
this. Further, if by operation we replace the diaphysis, it is by no means 
certain that we can prevent shortening occurring. Secondly, impaired move- 
ment at the shoulder- joint, especially in the direction of abduction and 
rotation. If these are much limited an operation is probably advisable, and 
still more so if there is evidence of pressure on the axillary vessels or the 
brachial plexus (both, however, rare). Thirdly, ankylosis of the shoulder. 
Much will depend on the peculiar circumstances of the case and the operative 
zeal of the surgeon ; but the example of Bruns' two cases and of Smith's is 
very encouraging in the direction of operation. If the diaphysis remains 
displaced to a considerable extent a very fair result may in many cases be 
expected, although shortening will probably occur. This is shown in the 
cases recorded by Puzey, Hamilton (two), and in one of my own. In all 
these firm union occurred, and movements at the shoulder-joint were very 
good. Owing to ossification in the connecting bridge of periosteum, we 
have little cause to fear non-union between the diaphysis and epiphysis. 
However, in two cases (both occurring at birth) recorded by Bertrandi and 
Durocher a false joint appears to have formed. 

In recent cases, after reduction care must be taken that the humerus be 
not rotated on its vertical axis,- especially in the inward direction. The 
epiphysis tends, as already said, to be somewhat abducted, but not to be 
materially rotated. It is inadvisable to use a bulky axillary pad, and a 
neatly fitting poroplastic shoulder-cap is one of the best forms of retentive 
apparatus. Weight extension can but rarely be required. — J. H. 



78 CHAPTER III. 

niusculo-spiral nerve is apt to suffer^ either as a direct result 
of tlie injury, or secondarily from pressure of callus_, in which 
it may be deeply embedded. On this account the surgeon 
should carefully examine for weakness of the extensors of 
the wrist and hand in order to make no mistake in the 
prognosis. Union results from correct treatment in a normal 
manner, but it is to be noted that a false joint is more common 
in the case of fracture of the humerus than of all the other 
bones of the upper extremity put together. This is due to 
difficulty in keeping the fragments at rest, and to the risk 
of interposition of the soft parts. 

Treatment. — If a circular bandage is made to include the 
upper arm, the shoulder, and the elbow, there is risk of dan- 
gerous pressure on the axillary vessels. 

Plaster of Paris is sometimes used, but well-padded metal 
splints (one long splint over the whole length of arm and 
forearm on outer side, with a shorter one on the inner 
side) will be found efficient, especially if it is arranged that 
the bandage shall keep up some extension. The splint is 
bent so as to receive the semi-flexed elbow, and its upper 
end is curved over the shoulder so as to be separated from 
it by a short distance (see Fig. 63) with an efficient pad of 




Fig. 63. — A splint for treatment of fracture of tlie humerus so 
applied as to keep up traction in the long axis of tlie bone. 



cotton wool in the armpit and bandage ; upward traction over 
the end of the splint is then forcibly made. This apparatus 
may also be used for fractures of the upper and of the 



Tab. 35. 




LithJnst.v. F. Reichhdld, München 



PLATE XXXY. 

Pig. .1. — Dissection showing a fracture about tlie junction of tlie 
lower and middle thirds of the right humerus (artificially produced, to 
show the relation of the musculo-spiral nerve to the site of fracture). 

Pig. 2. — United fracture with displacement of the shaft of the 
humerus. 

^ig- 3- — Pi'acture above the epicondyles with typical displacement, 
simulating backward dislocation of the elbow. 



FRACTTJEES OF THE HUMERUS. 



79 



lower ends of the bone. The so-called MiddeldorpFs tri- 
angular apparatus (see Fig. 64) is much used, and if there 





i^^ 


1 
1 




■K3 


i 




sV^'^* 


i 






ri 


M 






M 


lijy^ 1 




im 


w^ 




1 


y "' 


1 



Fig. 64. — Strong metal splint (not padded) applied to a fracture 
of the humerus ; it can be so arranged as to keep the arm 
abducted to a right angle. 

is a marked tendency to reproduction of the displacement 
strong extension may be required ; for this purpose the 
counter-extension should not be made from the axilla, but 
from the side of the chest. In such cases it is probably best 
to confine the patient to bed, when the counter-extension can 
be readily applied to the thorax, whilst a weight sufficient 
to maintain proper extension at the seat of fracture is 
applied to the abducted arm, which rests on a pillow and 
table close to the bed. Thus any undesirable pressure on 
the nerves and vessels in the axilla is avoided. 



F. Fracture of tJie lower end of the humerus. — Under this 
heading are included those fractures which occur below the 
upper part of the origin of the supinator longus. 

Their exact diagnosis is often a matter of much difficulty 



80 



CHAPTEE III. 



in spite of thorough palpation. "We may note first the 
normal relations of the bony points, and especially those of 
the epicondyles (see Figs. 65, 66, and 67) with the 



Fig. 65. — The lower end o£ tke humerus. The dotted lines point 
to the trochlea and capitellum, the internal and external epi- 
condyles, the fossae for the coronoid process and head of the 
radius in full flexion. 



Fig. 66. 



Fig. 67. 





Fig. 66. — A line passing between the two epicondyles when the 
elbow is extended cuts through the olecranon. 

Fig. 67. — Lines drawn from the top of the olecranon to either 
epicondyle when the elbow is bent to form an obtuse angle. 

olecranon. When the elbow is fully extended the trans- 
verse epicondylar line cuts through the tip of the olecranon. 
When the elbow is bent to a right angle the three points 
form a triangle whose plane is vertical (see Fig. 67). 

Further, it is most important in making the diagnosis 
to carefully compare the sound with the injured elbow. 
Although it is impossible to arrange all cases of fracture of 
the lower end of the humerus in strict tabular form, the 



Tab. 06. 




EtglcL 



^mM 




■'' Fig.lb 





Euf.^ 




■■<^, 



/^.«y 



Lith.Ansi y. K, Rpiohliold , Münclieii 



PLATE XXXYI. 

Figs. I a and i 6.— The bones of the right elbow, from a child|who 
had sustained a sex'ere injury by machinery. The lower epiphysis of 
the humerus was partially detached, and in addition there is an oblique 
fracture in the lower third of the shaft, with longitudinal fissure. 
Longitudinal fracture of the olecranon. Amputation was required. 

Fig. 2. — Longitudinal split in the humerus below a comminuted 
fracture of its centre due to a gun-shot injury. Recovery after ampu- 
tation. 

Fig. 3. — T-fracture of the humerus. 

Fig. 4. — Oblique fracture through the elbow-joint, detaching the 
capitellum and the external epicondyle. 
a. Fracture above the epicondyles. 
h. Fracture just above the articular eminences. 

c. Oblique fracture through the outer part of the joint. 

d. Oblique fracture through the inner part of the joint. 

e. Isolated fracture of the inner epicondyle. 

/. Isolated fracture of the external epicondyle. 
g. Intra-articular fracture of the capitellum. 



FßACTÜliKS OF THE HUMERUS. 



81 



following- varieties (illustrated in Figs. 68 and 69) may be 
distinguished. 



Fig. 68. 



Fig. 69. 



. — ä..^.:.Ä 




^ 




Pigs. 68 and 61^. — Different forms of fracture at the lower end of 

the humerus. 

(a) Fracture of the epicondijles . — This injury^ which is 
frequently met with in children^ generally results from a fall 
on the elbow or the hand. It may result from^ so to speak^ 
over-flexion or over-extension (Figs. 70 and 71); and the 
displacement^ the direction of the line of fracture^ and to 



Fig. 70. 



Fig. 71. 





Fig. 70. — Diagram of a fracture of the lower end of the 
humerus due to hyper-extension. Line of fracture oblique from 
behind, forwards and downwards. 

Fig. 71. — Similar diagram of a fracture from bending of the 
bone. Line of fracture oblique from in front, downwards and 
backwards. 

some extent the treatment will vary according to Avhich of 
these two causes has produced the fracture. 
t" Symptoms. — When the fracture has resulted from over- 

6 



82 GHAVTI<]R III. 

flexion the lower fragment tends to be displaced forwards, 
and the sharp end of the diaphysis to be forced into the 
triceps muscle ; in the more common fracture from over- 
extension the lower fragment is displaced backwards. If 
the two epicondyles are grasped, and the lower fragment 
moved, crepitus, or at any rate abnormal mobility, will 
be made out ; further, the forearm can be abnormally ab- and 
adducted. What displacement exists can be overcome by 
traction on the bent elbow, but tends to recur directly it is 
relaxed. 

Treatment. — Under full ansesthesia the displacement is 
reduced, and lateral splints applied, either in the extended 
or flexed position of the elbow-joint, according to which is 
found most effective. In adults, if the patient is kept in bed, 
weight extension applied to the fully supinated forearm (see 
Fig. 72), with if necessary some lateral traction or direct 



^ " V, 




nl'.ßV/^- 








Fig. 72. — Treatment by weight extension of a T-fracture into the 
elbow-joint. 

pressure (by a small sand-bag, &c.), will be useful. In 
children, a similar splint to that shown in Fig. 63 may be 
employed, but I cannot insist too strongly on the necessity 
for great care in effecting the first reduction, and in super- 
vising the after treatment. As a rule I employ an anaesthetic 
when first putting up the fracture, and sometimes even when 
readjusting the splint, &c., which should not be too long 
applied, in order that passive movement and massage should 
be commenced early. 

If the treatment is unsuccessful union may result in the 
position of valgus or varus (see Plate XXXVII). 



[One important fact has lately become clear, owing to the 
use of radiography. The mass of bone which is felt just 



Tab. 37. 




\ 



ElglcL 






V 




Eig.2o 



litliAisi.'r. F. Reiehhold , MüncJien 



PLATE XXXVII. 

VALGUS AND VARUS POSITION OF THE ELBOW FOLLOWING 
FRAOTUKE OF THE LOWER END OP THE HUMERUS. 

Fig. I a. — Oblique fracture like that shown in fig. i, which had been 
produced two years before the drawing was made. Patient a man 
aged thirty-four. The elbow is in a position of marked valgus. 

Fig. I. — Preparation from a similar case, showing evidence of ar- 
thritis deformans, thickening of the head of the radius, &c. The 
fracture through the lower end of the humerus had been oblique and 
the capitellum displaced upwards. 

Fig. 2. — Cubitus varus following an oblique fracture above the epi- 
condyles which had united with displacement. Arthritis deformans. 

Fig. 2 a. — Cubitus varus on the living subject, following fracture of 
the lower end of the humerus. 



FßAOTüh'KS OF THK HUMERUS. 83 

above the bend of the elbow in so many cases of sepa- 
rated lower epiphysis and the like at the end of treatment, 
which is put down to excessive callus^ and which so much 
limits the movements of the elbow, is not really callus at all, 
but the end of the shaft which was originally displaced and 
never reduced. 

The accompanying figures illustrate this well. The first 
one shows a side view of a separated epiphysis in a boy 
aged five, taken eight days after the accident. The injury 
had been carefully treated from the first on a splint, and 
the displacement was supposed to have been corrected. The 
skiagraph shows that the diaphysis still projected strongly. 



Fig. 73.-^Skiagrapli of a case o£ backward displacement of the 
lower epiphysis of the humerus, showing the usual deformity, 
taken from a boy aged five, some eight days after the accident. 
The displacement had been thought to have been reduced, and 
the arm had been kept in a rectangular splint. 

and that the projection would form a permanent obstacle 
to full flexion. Since it would be denuded in front of its 
periosteal sheath it would be impossible for the bone here 
to form excessive callus. On the dead subject I have found 



84 



CHAPTER in. 



it almost impossible to reduce such displacement as is here 
shown with manual traction, the elbow-joint being extended ; 
and what applies to manual traction must equally apply to 
Aveight extension. The next figure shows the result of as 
full flexion of the elbow-joint as the swelling would allow ; it 



Fig. 74. — rrom the same case as that shown above ; by full flexion 
of the elbow the epiphysis is brought into almost perfect posi- 
tion. This position was kept up for three weeks and an excel- 
lent result obtained. 



will be seen that the epiphysis has glided into almost perfect 
position, and there was no difficulty in keeping it there. 

Nothing could more clearly illustrate the value of putting 
up such fractures in the flexed position. — J. H.] 

As complications we have to note occasional injury to the 
ulnar, the musculo-spiral, or the median nerve, which have 
been known to be torn through; such injury would naturally 
require careful operative treatment. Sometimes also the 
brachial artery has been damaged, threatening gangrene of 
the arm. 

(6) Tranaverse fracture within the joint. — This form, which 



FRACTURES OF THE HUMERUS. 



85 



results from a fall on the hand or elbow^ is rare^ and usually 
the line of fracture passes partly outside the joint. It in- 
cludes traumatic detachment of the lower epiphysis (see 
Plate XLI, fig. 3, and Plate XXXVI, fig. i a). 

The displacement is usually not great ; besides the usual 
signs of fracture there is extravasation into the joint. 
Examination should be made under an ansesthetic^ and after 
reduction the fracture may be treated either by splints or 
weight extension^ and with the elbow either bent or extended. 
Early passive motion. 

(c) [d) Oblique fractures of the lower end of the humerns 
through the elbow-joint may break off either the capitellar 
or the trochlear portion, occasionally both at the same time,, 
and may be accompanied by much displacement of the bones 
of the forearm. The amount of swelling and pain on examina- 





F'K- 75- — Paralysis of extensors of wrist, due to a complicated 
fracture of the lower end of the humerus ; at the elbow a scar 
is seen over the site of fracture. Patient a boy aged eight. 



tion necessitates an anassthetic for the latter. It is usually 
possible by testing the lateral movement in extension of the 



86 CHAPTER III. 

elbow (ab- and adduction) , and by careful comparison with the 
opposite normal joint^ to effect a correct diagnosis. By far the 
most common form of oblique fracture is one passing down- 
wards from the outer side_, and breaking off the capitellum (see 
Plate XXXVII). It may result from direct violence — fall 
on the elbow — or indirect, the latter either from a fall on 
the hand transmitting the force through the radius, or from 
a fall on the inner part of the elbow with the arm abducted, 
transmitting the force through the olecranon. This external 
oblique fracture involves a varying amount of dislocation of 
the forearm outwards and backwards The piece of bone 
broken off is often displaced upwards, and perhaps rotated 
forwards ; crepitus, dislocation, and severe pain on passive 
motion will all be present. The prognosis of this fracture 
is on the whole not good, for only too easily the displace- 
ment may persist, leading to limitation of movement, partly 
through excessive formation of callus or projection of the 
fractured portion. It is true that in children and in young 
subjects, by menus of persistent passive and active motion, the 
amount of movement may be gradually increased ; but com- 
plete recovery in those cases is almost impossible, and cubitus 
valgus will probably remain.^ 

Treatment. — Under anaesthesia the displacement must be 
removed by direct pressure, with the forearm flexed and 
pronated, and the splints should be so applied as to change 
the position of the elbow every few days (now full or 
almost full extension, now flexion) . This change of position 

^ One most striking fact about these injuries to the elbow-joint is the 
frequency with which thej are found to be complex or composite lesions, — 
neither fracture alone nor dislocation alone, but fi'actvu'e-dislocations. 
Thus the capitellum may be fractured and displaced upwards, whilst the 
radius alone or both radius and ulna are dislocated upwards with it ; the 
internal epicondyle fractured with outward dislocation of both forearm 
bones ; the ulna fractured in its upper third, and the radius dislocated at the 
elbow. These are three well-marked varieties, but several more could be 
cited. I operated on a child who had sustained at the same time — 

1. A separation of the lower epiphysis of the humerus which had been 
displaced inwards en hloc, and had united in this position; 

2. A fracture of the capitellum ; and 

3. A complete outward dislocation of both forearm bones. 

By chiselling ofE part of the humerus the dislocation was (with difficulty) 
reduced, and a good moveable joint obtained. — J. H. 



FRACTURES OF THE HUMERUS. 87 

should be made every three or four days during the first 
fortnight^ and after that every two days. The padded metal 
splints^ which can be altered as regards the angle at every 
change of dressing, are amongst the most useful ; but con- 
tinuous weight extension may be tried, especially with the 
elbow flexed, and the traction made in the axis of the 
forearm. An oblique fracture, on the opposite or inner side 
involving the trochlear surface, is much less common, and 
results from force transmitted through the middle of the 
joint end (a fall on the elbow). The prognosis, on account 
of the displacement being less, is more favourable than in 
the last case. 

(e) Fracture of the internal &picori(i7/Ze is a frequent injury, 
sometimes resulting from a fall or blow on this projection of 
bone ; much more commonly it occurs from indirect violence, 
from traction exerted through the internal lateral ligament 
with the forearm forcibly abducted. The point of bone is 
at first detached, and then dislocation outwards occurs. 
The epicondyle is sometimes excessively displaced (even 
under the trochlea) ; there is extravasation of blood into 
the joint with abnormal mobility. In the treatment of this 
injury Kocher recommends if the epicondyle is moderately 
displaced that it should be fixed by operation, or in old cases 
removed by excision. As a result of the examination of the 
joint in several of these operations Kocher believes that 
this fracture is almost always due to traction, and that it 
directly predisposes to outward dislocation. 

The fracture of the external epicondyle is excessively 
rare, but I have known it, occur with an inward dislocation 
of the forearm. 

(/) Intra- articular fracture (f the capifellnm may occur 
from a fall on the hand, when the force is transmitted 
through the radius. The detached fragment, which, as 
Kocher has shown, may be little more than the layer of 
cartilage with some adherent bone, remains loose in the 
joint. 

The symptoms are sudden pain and appearance of a dis- 
tortion at the elbow — hsemarthrosis ; later on the arm is kept 
flexed to an obtuse angle, with the elbow slightly abducted, 
the internal epicondyle projects more than normal, the head 



88 CHAPTER III. 

of the radius appears to be subluxated, movements are free^ 
except full extension and supination, which are limited and 
painful. The detached capitellum may be clearly distin- 
guished. 

Treatment. — Excision of the detached piece of bone 
through an incision made in the outer side. 

Fractures in the form of a T, a Y, and a V are severe 
injuries, complicated not only by involvement of the joint, 
but also frequently by wounds of the soft parts. The lower 
end of the humerus seems particularly disposed to longitu- 
dinal fracture, such as is shown in Plate XXXVI, fig. 2 (the 
result of a gun-shot injury). A correct diagnosis is not 
impossible, since either lateral portion ol the lower end of 
the humerus can be moved on the other, and on the shaft. 
In the treatment antisej)tic dressings should be applied to 
the wounds with weight extension, the elbow being straight. 

Dislocations of the Elbow. 

We have to distinguish between dislocations of both 
bones, and those of one only (either radius or ulna) . 

A. Bachward dislocation of both bones. — No form of dis- 
placement is easier to produce on the dead body than this, 
first by hyper-extension sufficient to tear the capsule in front, 
and then forcible backward pressure with the forearm some- 
what bent. The elbow remains flexed at an obtuse angle, 
and flexion is difficult owing to the coronoid process being 
fixed against the end of the humerus. On the living 
subject the symptoms are very obvious, and include 
projection of the olecranon and head of radius backwards, 
and (to a less marked degree, owing to the covering of the 
soft parts) of the humerus forwards. The epicondyles are 
further removed from the olecranon than normal ; the length 
of the humerus is unaltered, but its axis is directed in front 
of the extremity of the elbow. Traction on the forearm 
does not cause the displacement to disappear. Occasionally 
this dislocation is complicated by other injuries, — for example, 
a fracture of the coronoid process, of the internal epicondyle, 
of the olecranon, or of the trochlear surface ; and the prognosis 
in such cases must naturally be worse. 



Tab. 38. 









lithJtasl.v. F. Reiohhöld, Mündien . 



PLATE XXXVIII. 

BACKWARD DISLOCATION OF THE FOEBAßM. 

Fig. I. — Dissection of a dislocation artificially produced. Of par- 
ticular interest is the condition of the annular and external lateral 
ligaments. 

Fig. 2. — Backward dislocation as seen in tlie living subject. The 
elbow is flexed to an obtuse angle, the olecranon projects abnormally, 
and the rounded head of the radius is seen just beneath the skin. The 
axis of the humerus lies in front of the ends of the forearm bones. 



DISLOCATIONS OF THE ELBOW. 



89 




Fig. 76. — Recent dislocation of tlie left forearm backwards in a 
boj aged fourteen, showing swelling about the elbow, promi- 
nence of the olecranon, and shortening of the forearm. 

Treatment.— The method of reduction is shown in Figs. 
77 to 80. The supinated forearm is first brought into 
hyper- extension^ so as to release the coronoid process from 
the olecranon, fossa ; then traction is made on the forearm, 
whilst the lower end of the humerus is fixed with the 
surgeon^s other hand, the thumb being placed in front, and 
the fingers exerting pressure on the olecranon, 1 

Flexion of the joint then completes the reduction. 

The after treatment includes fixation of the joint for 
fourteen days with repeated change of dressing and passive 
motion, and after that allowing free motion to the joint. 

Figs. 77 — 80. — Method of reduction of a backward dislocation of the 

elbow. 



":rs>.. 



-^r^- 



Fig. 77. — Hyper-extension of the elbow ns the first act in reduction. 
This is shown on the skeleton in Fig. 78. 



90 



OHAPTER III. 





Fig. 78.— (See description of Fig. 77.) 

Fig. 79. Fig. 80. 

/ 
J 





Fig. 79. — Downward traction on the forearm. 

Fig. 80. — Completion of reduction by flexion of the joint. 

B. Lateral didocations of ihe elbuiu. — These are not infre- 
quent, the outward variety being the most common, and 
being* often combined with a fracture of the internal epi- 
condyle. This fracture may be the result of direct violence, 
but is much more frequently due to the drag transmitted 
through the internal lateral ligament. The ulna, in this 
form of dislocation, rests against the capitellum, the head of 
the radius being free still further outwards : as a rule the 
forearm is at the same time displaced souiewhat backwards. 
The internal lateral ligament is either torn or the epicondyle 
dragged off. If the forearm is dislocated inwards the ex- 
ternal lateral ligament will similarly be torn through. In the 
first case the trochlea projects strongly under the skin, and 
the internal epicondyle is probably found to have been 
broken off ; in the second case the capitellum and external 
epicondyle project, unless the latter has been torn off, and 
on the opposite side of the joint the articular surface of the 
ulna can be felt. 

Treatment. — Under anaesthesia the elbow should be hyper- 
extended and direct lateral pressure made, followed by 
traction and flexion of the joint. If some obstacle interposes. 



Tab- 39. 





B 



^■2 



Fig. 3 




.% 



LithJlnsi v. K ReicHidld , München 



PLATE XXXIX. 

OUTWARD DISLOCATION OP THE FOREARM, WITH DETACHMENT 
OF THE INTERNAL EPICONDYLE. 

Fig. I. — Dissection of tlie right elbow seen from in front, showing 
lateral displacement of both bones of the forearm, with tearing off of 
the epicondyle, which is still connected with the ulna by the internal 
latei'al ligament. 

Fig. 2. — The same dislocation viewed from the oiiter side. The 
contour of the front and back of the arm and forearm are but little 
altered, but the head of the radius projects strongly under the skin. 

Fig. 3 shows the same dissected. 



DISLOCATIONS OF THE PJLBOW. 91 

repeated lateral movements (extension with abduction^ &c.) 
maybe sometimes of use. If however reduction fails the joint 
should be opened (best by two lateral incisions) ^ since by this 
means sometimes excellent results are secured. 

c. Forward dülocation of the elbow is a very rare accident^ 
which may occur from a blow or fall on the olecranon when 
the joint is fully flexed ; it is unnecessary to say more on 
this subject. 

Dislocation of one bone forwards and of the other back- 
wards is also very rare. In its treatment each bone must be 
reduced separately. Isolated dislocation of either radius or 
ulna is occasionally met with^ especially of the radius, the 
head of which may be displaced forwards, backwards, or 
outwards. 

Backward dislocation of the radius alone is very uncommon ; 
it can be easily recognised by palpation, the elbow is half 
pronated, and the patient is unable to extend or supinate 
the forearm. Eeduction is made by vigorous traction, direct 
pressure, and adduction of the forearm. 

Forward displacement of the radial head is more common, 
and may result from a blow on the back of the radius, or 
from a fall on the pronated hand. The head of the radius 
projects forwards above the capitellum, and produces an 
abnormal convexity in the region of the supinator muscles. 
The forearm is slightly flexed and pronated, active supina- 
tion is impossible, and flexion can only be done to about a 
right angle. If uncomplicated with fracture of the ulna in 
the upper third there will be shortening of the radial side 
of the forearm. Eeduction is best effected with the elbow 
bent and supinated by strong traction. In all these cases 
where the radius alone is dislocated the orbicular ligament 
is either torn, or the capitellum slips out of its grasp. Not 
uncommonly, particularly in the forward dislocation, reduc- 
tion is rendered difficult or impossible owing to the inter- 
position of part of the capsule. In these cases arthrotomy 
should be done, and reduction effected after dividing the 
interposed soft parts. In making the incision care should 
be taken to place it sufficiently far outwards to avoid the 
radial nerve ; only in the worst cases is resection instead of 
arthrotomy indicated. 



92 CHAPTBE nr. 

Under the name of internal derangement of the joint 
several intra-articnlar injuries are included ; one form we 
have already noted — a detachment of the capitellum of the 
humerus. Another variety deserves notice here^ and whilst 
its causation and symptoms are well known, its anatomy 
continually furnishes subject for controversy. It is met 
with only in young children, and occurs through a vigorous 
pull on the infant by the person who is leading it along, — as, 
for instance, when the child is likely to fall. The symptoms 
are as follows : — The child hangs the painful arm downward in 
a pronated position, and cries when supination is attempted. 
There is no obvious deformity at the elbow. If the forearm 
be supinated whilst traction is made, and then the elbow 
flexed, the symptoms disappear, and the child will again use 
the arm ,- it is, however, better to keep the part quiet on a 
sling for a few days. These cases, which exactly resemble 
each other, are explained by some surgeons as being due to 
an incomplete form of dislocation of the head of the radius, 
by others as a nipping of the undamaged capsule of the joint 
(the posterior part) between the head of the radius and the 
humerus.-^ 



Fractures of Both Bones of the Forearm. 

These result chiefly from falls or blows. Amongst children 
greenstick fracture is not uncommon. The middle third of 
the bones is usually involved, and if they are broken about 
the same level the displacement is more marked than if the 
fracture involves one bone at a different level from the other. 
Should the bones be much displaced towards each other, union 
may occur between them, or a sort of articulation result, as 
shown in Plate XL, fig. 3. In both cases the use of the fore- 
arm will be much interfered with. The treatment of these 
fractures deserves special note, and calls for much skill. One 

^ There is really no cause for further controversy on the nature of this 
accident. It is undoubtedly and invariably due to the cartilaginous head 
of the radius slipping out of the grasp of the orbicular ligament. When 
the forearm is flexed and then fully pronated, the radial head again returns 
to its place. These facts can be perfectly worked out by experiments on 
the dead subject. — J. H 



Tab. 40. 




■A^ 




FA£l.i 





:"i- % 



x:^. 



Llth-änsix F ReiBWidld, Mündifn 



PLATE XL. 

FRACTURES OF THE FOREARM NEAR ITS CENTRE. 

Fig. I, — Typical deformity due to a fracture occurring in a boy who 
came under observation when the fracture had begun to unite. Under 
an ansesthetic the union was broken down, and the limb carefully put 
up on a dorsal splint with the elbow extended. A good result followed. 

Fig. 2. — The bones of the right forearm seen from in front, from a 
case similar to that shown in fig. i. The radius is firmly united by 
bone, the ulna shows a false joint, and both bones present an angular 
bend. 

Fig. 3. — Specimen from a fracture of both bones united in fairly 
good position, but with great limitation of rotatory movement, due to 
pi'ojections of new bone from both radius and ulna, which fit together. 
There was marked arthritis deformans in elbow and wrist joints. 



PEAOTURES OP BOTH BONES OE THE FOKEAliM. 93 

must be very careful that tlie retentive apparatus does not 
press the two bones towards each other. The first point 
then is to see that the splints are wide enough to project 
along the sides of the forearm. The second point is in what 
position to maintain the forearm ; naturally the elbow is to be 
bent to a right angle^ and the wrist extended. Almost com- 
plete supination will best ensure the bones being kept 
parallel. Plate XLI^ fig. 2, shows how the upper fragment 
of the radius will be supinated by the biceps. Should then 
the lower fragment unite in the pronated position^ marked 
loss of the poAver of rotation will obviously result. 

Fig. 81 illustrates what we may term a supra-condylar 
fracture just above the wrist^ in which the tendency of the 
bones towards approximation is well marked. We must 
therefore lay stress upon careful adjustment of the fracture 
in the supinated position, with the use of sufficiently wide 
splints applied to the dorsal and anterior surfaces of the 
forearm. The splints must be really well padded, and the 
fingers left free. At the end of eight days they should be 



'V- 



Fig. 81. — Fracture of both bones o£ the left forearm a short 
distance above tlie wrist. 

removed, and the fractured part examined. If a lateral 
projection at the site of fracture is threatened, an additional 
splint may be required. At the second change of dressing 



94 OHAPTIiR lit. 

passive motion and massage should be begun. Delayed for- 
mation of callus or false joint should be treated in the 
manner already described. 

Fractures of the Utiia (Plates XXXVI andXLII). 

A. Fracture of the olecranon. — This results as a rule from a 
fall on the elbow^ from direct violence, very rarely from mus- 
cular action alone, or from the olecranon being pressed against 
the humerus in hyper-extension. The symptoms of the fracture 
are simple, since it is nearly always a transveise one, and 
since the upper fracture is drawn upwards by the triceps. 
There is always extravasation of blood in the joint. The 
patient cannot extend the elbow. Asa rule the upper frag- 
ment can be drawn down sufficiently to procure crepitus. In 
those exceptional cases where the periosteum and lateral parts 
of the triceps are untorn the prognosis is naturally the most 
favourable, since bony union will almost certainly occur. In 
the commoner cases where the fragments have been separated 
fibrous union is the rule. This is partly owing to the fact 
that there is no periosteum on the joint aspect, but only a 
thick layer of cartilage, and on either side the fibrous 
insertion of the triceps ; hence callus is formed with diffi- 
culty. 

Treatment. — The arm must be put up with the elbow fully 
extended, so that the upper fragment which is drawn up by 
the triceps is approximated as much as is possible to the 
lower one, and it may be fixed in this position fairly well by 
narrow bands of strapping, which loop over the top of the 
olecranon. It is obvious that the line of fracture must in- 
volve the elbow-joint, and sometimes it is advisable to 
evacuate by puncture the extravasation into the latter which 
may be keeping up the separation. An early resort to 
massage is advisable, and of late has been recommended from 
the first, and it would appear to have given good results. 
Primary suture of the fragments may be carried out if the 
aseptic methods of the operator can be relied upon, and if 
undertaken with the resources of a surgical clinic is quite 
justifiable, though as a universal method it is certainly not 
to be recommended. 



Tab. 41. 




LüttJim.v.F.ReicWiold, Münclieii 



PLATE XLI. 

Fig. I. — Fracture at the centre of radius and ulna, in wliicli the 
callus has bound the two bones together. No doubt the splint used 
was not broad enough, and the two bones have been allowed to con- 
verge at the site of fracture. 

Fig. 2. — Fracture of the radius alone (experimental), showing how 
the upper fragment is supinated by the biceps, whilst the lower frag- 
ment is in full pronation when the hand is turned over. Union under 
these circumstances would be attended with complete loss of the power 
of rotation. 

Fig. 3. — Section through the bones forming the elbow-joint in a 
young subject, showing the epiphysis at the upper end of the radius, 
and two bony nodules in the lower epiphysis of the humerus, one for 
the capitellum, the other for the trochlear surface. 

Fig. 3 a. — Vertical section through the upper end of an ulna, from a 
child. 

Fig. 4. — Lower epiphyses of the radius and ulna. 



Tab. 42. 




Fig.1 



lithinsty. F.Reichhdld . Müntiieii 



PLATE XLII. 

FEACTURES OF THE OLECRANON AND CORONOID PROCESS. 

Fig. I. — Dissection of an artificially produced fracture of the ole- 
cranon. The drawing shows how the elbow-joint is opened in such an 
injury, and how the upper fragment will tend to be drawn upwards by 
the triceps. 

Fig. 2. — Specimen of fractured olecranon which had been united by 
fibrous tissue as shown in fig. 3. 

Fig. 4. — Fracture of the coronoid process at its base, showing dis- 
placement due to brachialis anticus. 



PliAOTÜKES OF THE ULNA. 95 

B. Fracture of the coronoid process. — This fracture is un- 
common^ and is met willi most often as a complication of 
dislocation of tlie forearm. It is only when the process is 
broken oif at its very base that the brachialis anticus 
muscle is likely to draw it up. Since this muscle is inserted 
considerably below the tip of the process^the fracture probably 
occurs from violent pressure against the lower eud of the 
humerus. 'J'he symptoms include those of a severe injury to 
the elbow-joint. It is impossible to feel the detached frag- 
ment plainly owing to the thickness of the soft parts in front. 
The olecranon is somewhat displaced backwards^ but with 
direct traction returns into place. If the elbow be placed 
at an obtuse angle it is easy to obtain this subluxation of 
the olecranon^ and crepitus may be felt. 

The treatment consists in traction ( n the forearm sufficient 
to get the u.lna into place ; then the elbow is put up, 
flexed to an acute angle, whilst the usual measures for the 
treatment of a fracture into the joint are carried out. 

c. .Fracture of the idiia in the upjier third irith s'nniil- 
taiLcoii.s dl.slocation (f the liead (f the radius (Plate XLIIl). 
— In the corresponding parts of the body which contain two 
parallel bones, viz. the forearm and the leg, it may be noted 
that should both those bones be fractured considerable dis- 
placement may be present, but if one only is broken the 
other may act as a splint and prevent displacement. 

Now if it appears that one only is fractui-ed, and yet there 
is marked deformity, it must necessarily follow that the other 
one is fractured too, or is dislocated. The practitioner will 
note that fracture of the ulna, if accompanied by marked 
displacement, is likely to involve a dislocation of the radial 
head. Fracture of the tibia similarly may involve dislocation 
of the upper end of the fibula. Plate XLIII well illustrates 
the characteristic appearances of the mixed fracture and 
dislocation as I have often observed it on the living sub- 
ject. In such cases the fracture is not likely to be over- 
looked, but the dislocation of the radius easily escapes dia- 
gnosis. 

As seen in the plate, the radial head may rest on the shaft 
of the humerus above the epicondyle, or it may not be so 
completely displaced as this. The prognosis is favourable 



96 CHAPTER III. 

if only a correct diagnosis be made. Under an ansesthetic 
direct traction is made on tlie forearm^ so as to get the 
fracture into good position ; further^ with the elbow flexed^ 
pressure is made upon the head of the radius^ so as to force 
it into its normal position. There will probably be a 
tendency to recurrence of the displacement, and to obviate 
this the elbow should be put up in the flexed position and 
supinated on a back splint, so that direct pressure may be 
employed through a pad over the radial head. 

In old cases of this kind osteotomy at the point of fracture 
of the ulna, and an arthrotomy with reposition of the radial 
head, or its resection, may be necessary. 

D. Fracture of the ■ulnar shaft. — In the case of a fall with 
the elbow bent, or in warding off a blow with the arm, the 
ulna may sustain the brunt of the injury, and thus its shaft 
be broken by direct violence. From an indirect cause such a 
fracture is of extreme rarity. 

The diagnosis is easy, for owing to the superficial position 
of the ulnar shaft abnormal mobility and crepitus are easily 
obtained. 

The treatment is conducted on the same principles as that 
for fractures of both bones of the forearm ; marked displace- 
ment can hardly occur if the radius be intact. The styloid 
process of the ulna is frequently broken off in cases of 
Colles^s fracture of the radius ; it is very rarely broken 
alone. In either case union by fibrous tissue will probably 
result. 

Fractures of the Radius. 

A. Fracture of the Jiead. — This is wholly intra-articular ; it 
may be complete or incomplete (fissure or bending) . In the 
latter case the diagnosis is naturally difficult and uncertain. 
Cases of complete fracture are to be recognised when the 
head of the radius is abnormally moveable with crej)ituSj 
but it may be noted that in such cases the movement of the 
head in pro- and supination seems to be unaffected. Pain 
is naturally localised to the region of the radial head. This 
fracture may be due sometimes to direct, more frequently to 
indirect violence^ and the elbow may be either extended or 



Tab. 43. 




Fig.1 




Eig.2 



LithJnsi.v, F.Reichhold, München 



PLATE XLIII. 

DISLOCATION OF THE HEAD OF THE RADIUS WITH FRACTURE 
OF THE ULNA IN THE UPPER THIRD. 

Fig. I, — The left elbow seen from the oviter side. There is raarked 
displacement at the site of fracture in the olecranon, and the head of 
the radius rests above the external epicondyle. 

Fig. 2. — The same injury taken from a, photograph of a young sub- 
ject. The angular bend of the ulna and the projection of the radial 
head are all shown. 

Fig. 3. — A vei'y similar dissection to that given in fig. i, the radial 
head being, however, displaced moi-e directly upwards. 



FRACTURES OF THE RADIUS. 97 

flexed at the time. There are naturally present the signs 
of injury to the joint^ and not infrequently this fracture is 
overlooked^ and considered to be only a contusion or distortion 
of the ellDOw. Occasionally the radial nerve is damaged at 

Fig. 82. Fig. 83. 







Figs. 82 and 83. — Fracture of the head of the radius which has 
united by bone. It was obtained by resection from a woman 
aged twenty-eight, who had fallen on the outstretched hand. 
The joint was stiffened at an obtuse angle, and pronation was 
limited. 

the same time. Since one can make no direct pressure on 
the small upper fragment, union will probably take place^ in 
spite of all precautions, with considerable deformity and 
limitation of movement, which may later justify operation 
and resection of the radial head. Fractures of the neck 
of the radius and traumatic separation of the upper epiphysis 
are both extremely rare, as also are fractures of the radial 
shaft alone. 

B. Fracture of the loiver end of the radius (Plates XLIY^ 
XLY, XLVI, XLVII).— This form of fracture is very 
common, and of the greatest practical importance. Its 
symptoms are remarkably constant. The line of fiacture 
usually runs from i^ to 2 cm. above the articular surface, 
i. e. where the compact bone of the diaphysis passes into the 
spongy tissue of the articular end. Not infrequently the 
lower fragment does not include the whole articular surface, 
since the line of fracture passes into the latter, breaking off 
a small portion of it. 

The cause of the fracture is almost always a fall on the 
hand, the thumb side of which receives the impact. The 
wrist is forcibly extended, and the cancellous tissue of the 

7 



98 CHAPTER III. 

lower end of the radius gives way rather than the strong 
anterior ligament of the joint. At the same time the violent 



Fig. 84. — Skiagraph of the hand of a woman aged fifty-four, showing 
a transverse fracture of the lower end of the radius. 

pressure transmitted through the upper carpal row has 
probably a good deal to do with the fracture. In any case 
the lower fragment is driven backwards. 

Since the ulna has no direct relation to the wrist-joint, 
we can understand why as a rule it escapes injury in Colles^s 
fracture. 

The exact position of the line of fracture may differ con- 
siderably ; sometimes it is only the styloid process of the 
radius or a thin lamella of the articular end which is broken 
off, at other times the fragment is considerably larger, perhaps 
corresponding to the original epiphysis. The fracture may 
be very oblique, and in such cases, owing to the marked 
tendency to displacement, the prognosis may be less favourable 
than usual. ^ Occasionally the injury is due to a fall on the 

1 Mr. D'Arey Power has shown, from the examination of fifty- nine speci- 
mens of Colles's fracture, that a vertical split of the lower fragment is a very 
frequent complication, being present in no less than thirty-one of the speci- 
mens. There may be more than one fissure into the wrist-joint, and occasion- 
ally the lower fragment is really comminuted. The point is of some practical 
interest, since the wrist-joint is necessarily involved, but there is no doubt 
that even then recovery often results without any impairment in the func- 
tions of this joint. It is, as a rule, quite impossible to diagnose during life 
this splitting of the lower fragment (see ' Path. Trans.,' 1887, p. 250). — 
J. H. 



ja 






PLATE XLIV. 

TYPICAL FRACTURE OF THE LOWER END OF THE RADIUS. 

Fig. I . — Longitudinal section thvougli the middle line of tlie forearm. 
The projection forwards of the lower end of the upper fragment into 
the pronator quadratus muscle and the corresponding holloAv at the 
back of the wrist are evident. 

Fig. 2 shows the usual deformity. 



Tab. 45, 






lia.l 




Ei^.2 




rig. 





Fig. 3 



F^^-^ 



Lith.Ansr.v. F.R.eiohhold , Jslüitcliir, 



PLATE XLV. 

COLLBS'S FRACTURE. 

Figs. I and 2. — Specimens sliowing impaction of the shaft, but the 
lower fragment united by bone, and with the articular surface for the 
carpus tilted backwards. 

Fig. 3. — Fracture artificially produced, showing the displacement 
towards the radial side, and the abnormal projection of the styloid 
process of the ulna. 

Fig. 4 shows the typical deformity on the living subject. 

Fig. 5. — Old Oolles's fracture with marked arthritis deformans. The 
radius in this case is the same as that shown in Fig. 3. 



FRACTURKS OF THK RADIUS. 99 

back of the liand^ when the displacement will be in the 
direction of the palmar aspect. The symptoms are charac- 
teristic enough^ but a very careful examination should be 
made in any doubtful case. The surgeon should seat 
himself facing the patient, whilst the latter places both 
hands, with the forearms bare, so that they are exactly in a 
symmetrical position. If a Colles^s fracture is present the 
following points will be noticed. The styloid process of the 
ulna projects more strongly than on the sound side (see Plate 
XLV, figs. 3 and 4) ; the hand is pushed towards the radial 
side, so that the line of axis of the forearm passes through 
the ring or little finger instead of the middle one ; the region 
of the styloid processes appears to be increased in width. 
When the surgeon examines the part from the side, an ab- 
normal projection is noticed on the palmar aspect of the wrist, 
and an abnormal depression on the dorsal. In other words, 
there is a sort of bayonet projection due to the displacement 
backwards of the lower fragment. This displacement on the 
radial side is due far more to the line of action of the force 
which produces the fracture than to any muscular contrac- 
tion. 

It should be noted that the ordinary symptoms of a 
fracture are not always pronounced ; for instance, abnormal 
mobility may be absent owing to impaction, and in any case 
is difficult and unnecessary to produce. The same applies 
to well-marked crepitus. There will probably, however, be 
tenderness exactly over the line of fracture, and digital 
examination to determine this is a great assistance in 
confirming the points already noticed in dealing with the 
inspection of the injured part. 

The prognosis depends chiefly upon the treatment ; if the 
latter be properly carried out perfect recovery in every 
sense may result. 

In my possession is the specimen from a recently united 
Colics' s fracture in an old woman, who died shortly after her 
recovery from the injury, from pneumonia. It shows bony 
union without the slightest displacement. 

Treatment. — Reposition nmst be effected by direct pres- 
sure and traction on the hand whilst the latter is forcibly 
bent. This is best done under an anaesthetic , It is 



TOO OHAPTEE III. 

advisable to have two assistants ; one of them grasps the 
patient's hand, the other the upper arm, as shown in Figs. 
85 and 86, If reduction is eifected in the manner indicated 



■x 




\ 



Fig. 85. — Method of reducing imp^etion in a case of CoUen's 
fracture. 






fijo-. 86. — A slightly different method of making traction from that 
shown in the previous figure. 

there is, as a rule, no tendency to new displacement. The 
apparatus or splint must fix only the forearm, the wrist, and 
carpus. It is unnecessary to fix the elbow, and it is wrong 
to confine the fingers, since if the latter be fixed for some 
time troublesome stiffness will result in many people, a 
stiffness which may never be recovered from, and which in 
any case requires a painful after-treatment in the way of 
massage and passive motion. The hand must be flexed, and 
more bent, if possible, on the radial than the ulnar side, 
whilst the tendency to abduction is overcome. 



FKACIUKES OF THE JJAD1ÜS. 101 

These objects can be obtained by tlie use of a plaster-of- 
Pai'is splint (Fig. 87)^ or a bent metal one (Fig. 88). The 



Fig. 87. — Application of plaster-of- Paris splint after reduction of 
the displacement. The patient's thigh serves as a support for 
the forearm, whilst the hand is hent over the knee. 



lU 



■"^"^^äv^^ 




Fig. 88. — Position of the hand on a palmar splint bent in two 
directions, as recommended by Schede. The splint is shown 
alongside, and the direction of the turns of bandage indicated 
by arrows. 

following method 1 have found of special value : — After 
complete reduction of the deformity, and full adduction of 
the wristj a band of strapping about 10 cm. wide is ap- 
plied around the lower end of the forearm, whilst a second 



102 'GHAFTER "ITT. 

one surrounding the forearm a little higher up leaTes a gap 
through which suspension can be arranged in the manner 
shown in Fig. 89. I have used this method myself in only 



\ 



,f t /■ 



|5 



,/ *" ~<, ^ 



Fig. 89. — Colles's fracture treated -without splints by bands of 
strapping and suspension. 



five cases^ but Storp has had an experience of it in no less 

than 108 cases, in only four of which was it found unsuitable. 

In exceptional cases it may be necessary to keep the 

forearm fully supinated, as shown in Fig. go, where Roser's 



«t 




\ 



--.t- - 



l*"ig. 90. — Roser's apparatus for treating Colles's fracture in full 
supination. 



FRAOTUUb^S OF THE RADIUS. 103 

splint^ which seems to me unnecessarily cumbrous^ is applied. 
It must never be forgotten that Colles's fracture requires 
frequent change of apparatus, early massage^ and active 
motion. 

It is certainly better that such a case should recover 
with slight displacement^ but with perfect mobility of the 
fingers and wrist^ than without displacement^ but with 
greatly impaired mobility. If the fracture has been compli- 
cated with detachment of tlie styloid process (see Fig. 91), 




Fig. 91. — Colles's fracture of the radius, with detachment of the 
styloid process of the ulna united (so far as the radius is con- 
cerned), with but little deformity. 

or with a fracture higher up through the ulna^ the mobility 
of the lower radio-ulnar joint may be impaired^ and occasion- 
ally excision of the loose styloid process may become neces- 
sary in order to improve the range of movement. 

Separation of the lower radial epiphy.ns is fairly common 
in young subjects ; the symptoms and treatment of this 
injury are very similar to those of Colles^s fracture."^ 

^ Separation of this epiphysis was one of the earliest to be clearly recog- 
nised, Cloquet recording a case sixty-five years ago. The separation occurs, 
as a rule, exactly at the epiphysial line, though some fragments of the poste- 
rior edge of the diaphysis may be driven backwards with the displaced 
epiphysis. The injury is nearly always due to a fall on to the front of the 
hand; in all the recorded cases the age of the patient has been between 



104 CHAPTER III. ^ 

Dislocation of the lower radio ■ulnar joint is very rare, in 
spite of the weak ligaments and frequent exposure to injury 
of tlie part. The lower end of the ulna may be displaced 
backwards in a fall, or from forced pronation ; or forwards, 
owing again to a fall, or in excessive supination. Amongst 
washerwomen we sometimes see a sub -luxation of this joint, 
arising from continual rotatory movements during washing- 
clothes. There is nothing special to say about the symptoms 
or treatment. 

Dislocation of the hand at the nidio-carpal joint is extra- 
ordinarily rare, and we know that in the past the cases that 
were diagnosed as such were almost all examples of CoUes's 
fracture. The instances of undoubted dislocation which have 
been recorded only number about thirty, and some of these 
were complicated with fracture of the styloid process and 
radius. They were due to falls on the outstretched hand, 
which was strongly bent forwards or backwards at the time, 
and the carpus might be displaced backwards or forwards 
accordingly. Little difficulty exists in the diagnosis or the 
reduction. 

five and nineteen. When the epiphysis has been merely loosened the 
diagnosis may be difficult, and it is perhaps just in such cases that neglect 
of" treatment may lead to premature ossification and arrest o£ growth at this 
important epiphysial line. The ulna continuing to grow pushes the hand 
over, producing in the course ot a few years a characteristic deformity. 
When the displacement backwards of the epiphysis is complete the rectan- 
gular end of the diaphysis projects through its periosteal sheath, and 
perhaps even through the skin. The wrist-joint is not open, but the 
capsule of the lower radio-ulnar joint is often torn, and sometimes the 
styloid process of the ulna or the lower end of its shaft is broken at the 
same time. The accident if compound is a grave one, and many deaths 
have occurred from it due to suppuration and pysemia, gangrene, tetanus, 
&c. In the treatment of these compound cases thorough disinfection 
should be carried out. The wound should be enlarged, so that any obstacle 
to reduction, such as interposed tendons or periosteum, can be recognised 
and held aside. If there is much difficulty, or if the bone has been much 
contused, it is best to saw off the projecting end, since the periosteum will 
readily fill the gap, and the growth will probably not be interfered with. 
In simple cases, provided that proper reduction is effected under an 
an£Bsthetic, and the forearm kept on straight splints for three weeks, the 
ultimate result is almost perfect. I liave followed up six cases, and in only 
one was there any arrest of growth. — J. H. 



Tab. 47. 




Fig. 1 a. 




Fig. 2 a. 




Fig. 3 a. 




Fig. 4 a. 




Fig.i 





Fig. 3 




Fi^.k 



lithJnsi .V. K Reichhold . Mftnchm 



PLATES XLYI and XL VII. 

ILLtrSTEATING THE DIAGNOSIS BETWEEN THE DIFFERENT FRACTURES 
AND DISLOCATIONS ABOUT THE WRIST-JOINT. 

Figs. I and i a. — Fractui-e in tlie lower fonrtli of the forearm, with 
marked backward bending of the bones. 

Figs. 2 and 2 a. — Colles's fracture (compare Plate XLIV). 

Figs. 3 and 3 a. — Dorsal dislocation of the carpus, artificially pro- 
duced. 

Figs. 4 and 4 a. — Ditto of the metacarpus. 



INJURIES TO THE HAND AND FINGERS. 105 



Injuries' to the Hand and Fingers. 

A. Fracture><. — Fractures of tlie carpal bones are rare^ 
and are cliiefly observed when tlie soft parts are much torn 
or crushed^ the gravity of the lesion depending on the 
latter complication. 

Fractures of the metacarpal bones are more common^ and 
result from direct violence such as a fall or blow. Abnormal 
mobility and crepitus will be noticed^ with sharp pain at the 
point of fracture. There is but little tendency to displace- 
ment, since the adjoining metacarpal bones act as a splint^ 
and the treatment is correspondingly simple. 

Fractures of the phalanges chiefly result from direct 
violence, but sometimes from an indirect force acting in the 
long axis of the finger, and in the case of the terminal 
phalanges may even result from a violent pull through the 
tendons attached. The symptoms and treatment (with small 
padded splints) of these injuries are very simple, on account 
of the exposed position of the parts. 

15. Dislocations. — We hardly ever observe dislocation of 
one carpal row on the other, but single bones of the carpus 
may be displaced, and form an abnormal projection on the 
dorsum of the hand. 

Occasionally one metacarpal bone is dislocated from the 
carpus, most frequently that of the thumb_, which may be 



Fig. 92. — Slviagrapli of typical backward dislocation o£ the first 
plialanx of the thumb, in a boy aged sixteen. 

displaced towards the dorsum, or less commonly towards the 
palm or the radial side (see Plates XLVI and XLVII, fig. 4) . 



106 CHAPTER III. 

Dislocations at the metacarpo-phalangeal joints are rare in 
the case of the second to the fifth digits^ but in the thumb 
are more numerous, and very important in practice. The 
first phalanx of the thumb is displaced backwards to the 
dorsal surface of the metacarpal bone. If parts of the joint 
ends are still in contact we speak of an incomplete disloca- 
tion. It is quite possible to produce these dislocations by 
hyper- extension and forcible backward pressure on the dead 
subject, and to study in this manner the cause of the 
difficulty met with in reduction. 

Symptoms. — The most marked of these is fixation of the 
displaced bone, due to the traction of the powerful muscles 
and stretched ligaments on the part. The lateral ligaments 
are probably in most cases not torn through, and the inser- 
tions of the short flexor muscle, &c., on either side, so to 





Fig. 93. — Faulty method of attempting reduction b}^ simple 
traction. Each pull makes reduction more difficult. 

speak, button-hole the metacarpal head, and this prevents 
reduction by simple traction on the axis of the thumb. It 
is hardly necessary to lay stress on the abnormal projection 
of the metacarpal head in front, as well as the altered direc- 
tion of the first phalanx. 

A frequent obstacle to reduction is found in the inter- 
position of the capsule, with the attached sesamoid bones. 
In other cases the tendon of the flexor longiis pollicis may 
be hooked round the metacarpal head and prevent reiiuetion. 

This complication may be recognised by slight inclination 
of the thumb towards the ulnar side, and may be overcome 
sometimes by still further adducting the phalanx. 



Tab. 48. 




Eig.2 




Eigl 



LltKtosl.v. F.Reiehhold, Mändim . 



PLATE XLVIIL 

BACKWARD DISLOCATION OF THE THUMB. 

Fig. I. — Dissection showing the base of the first phalanx displaced on 
to the neck of the metacarpal bone, on the ulnar side of which lies the 
tendon of the flexor longus pollicis, whilst on the outer side of it is 
seen the abductor and part of the short flexor muscles. 

Fig. 2. — The same dislocation shown on the living subject. 



INJURIES TO THE HAND AND FINGERS. 107 

Exceptionally attempts at reduction may result in twisting 
the capsule and the outer sesamoid bone round between the 
two joint surfaces. 

It is essential in carrying out reduction first to hyper- 
extend the thumb, and then by direct pressure against the 
base of the phalanx to lever it over the metacarpal end. If 
these efforts fail arthrotomy must be carried out. In all 
such cases that I have hitherto treated I have succeeded in 



y^ 





-p\g. 94. — Correct method, showing the phalanx hyper-extended, 
and then drawn downwards. 

finding through an incision in front of the projecting meta- 
carpal head the cause of the difficulty in reduction, in 
effecting the latter, and in securing a moveable joint. In 

' A method which Prof. Helferich does not allude to will be found more 
satisfactory than the one mentioned in the text. It is illustrated in 
Fig-. 98. Instead of an open arthrotomy in front of the joint a puncture 
is made with a tenotomy knife from the dorsal aspect, and the glenoid 
ligament is divided between the sesamoid bones, the knife cutting down- 
wards until it comes in contact with the base of the first phalanx. Directly 
the glenoid ligament is completely divided it gapes, and slight pressure 
will allow the head of the metacarpal bone to return into place. By this 
method, which was long ago introduced by French surgeons, no structure of 



108 



CHAl'TliK III. 



old cases resection of the metacarpal head may be necessary. 
Dislocations of the first phalanx of the other fingers are 




Fig. 95. — The interposed capsule as an obstacle to reduction. 
Fig. 96. Fig. 97. 




Fig. 96. — Tiie sesamoid bones Interposed. 

Fig. 97. — The tendon of the flexor longus pollicis fixed at the 
back of the metacarpal head, and acting as an obstacle to reduc- 
tion. 



Base of First Phalanx 



Position of Puncture p. 
and direction of 
deep incision y^^ 




Projecting Head of 
Metacarpal 



Fig. 98. — Backward dislocation of the first phalanx of the 
thumb. The small arrow marks the point at which the knife 
should be entered in order to divide the glenoid ligament, i. e. 
on the dorsum close to the extensor tendons ; it also shows 
the direction in which the cut should be made downwards 
against the displaced phalanx. — J. H. 

usually of the backward variety ;, as in the thumb. Here 
also the capsule may be interposed. These dislocations are 

any importance is divided except the glenoid ligament, which is the one 
great obstacle to reduction, and the skin wound is merely a puncture. — 
J. H. 



INJURIES TO TUK HAND AND FINGKES. 



109 



not infrequently compound ; reduction is effected by hyper- 
extension and direct pressure. Dislocations of the other 



Metacarpal Bone 
of Thumb 




Fig. 99. — Diagram showing the metacarpo-phalangeal joint of 
the thumb, a and B are the two hands of the lateral ligament, 
the former being attached largely to the sesamoid bone D. At 
c is the firm attachment of the glenoid ligament to the phalanx, 
which always remains intact in the dislocation. — J. H. 



Fig. 100. — Dorsal dislocation of the second phalanx of the little 
finger, from a boy of fifteen. 




Fig. loi. — Doi'sal dislocation of t!ie second phalanx, middle finger, 
shown in section. 



Fig. 102. 



Fig. 103. 




Figs. 102 and 103. — Dorsal and palmar dislocation of the terminal 
phalanx. 



110 CHAPTER III. 

phalanges are not very infrequent^ and are sometimes 
reduced by the patient himself. They may occur backwards, 
forwards, or laterally. Neither the diagnosis nor reduction 
offers any difficulty. 



CHAPTER lY. 

FßACTüRES AND DISLOCATIONS OF THE LOWER EXTREMITY. 

The injuries of the lower limb are so far of greater im- 
portance than those of the upper^ in that they call for not 
merely the correct treatment of the particular injury^ but also 
special care in the matter of the general condition of the 
patient. In the case of fractures of the thigh_, &c., in old 
and weak patients especially, it is of importance not to con- 
fine them to bed for long, but to allow them to sit up as soon 
as possible, with suitable apparatus, for fear of hypostatic 
pneumonia. 

Fractures of the 'pelvis (see Plate XLIX) occur as a rule only 
from severe injuries, such as a fall from a great height, being 
run over, &c. We may have either true fractures of the 
pelvic girdle or diastasis at either the sacro-iliac joint or the 
pelvic synchondrosis. 

It is obvious that the diagnosis may be difficult unless the 
bones have been completely separated. 

Fractures of the ilium are rarely complicated by injury to 
the contained viscera, and although they may unite with 
considerable displacement, will probably give rise to no 
trouble. Those of the pelvic girdle are more important on 
account of the injuries to the soft parts which so often com- 
plicate them. Of these we may mention damage to the 
great sciatic and other nerves, to the femoral vessels, to the 
bladder, to the rectum — all of these being rare ; whilst much 
more frequent, and of the greatest practical importance, are 
injuries to the male urethra, which latter make themselves 
known by the escape of blood and hsematui-ia. The introduc- 
tion of a catheter is not only of diagnostic, but also of thera- 
peutic importance. If it is found impossible to introduce it, 
there is obvious danger of extravasation of urine, with all the 



112 



OFTAPTEß TV. 



Pyriforniis 

Gluteus max. 
Gemellus superior - 
01)lurator internus 
Gemellus inf. 



Great sciatic nerve 




Gluteus mediiis 

Gluteus miiiimvis 

Head (if femur 
Gluteus medius 
Great troclianler 
Obturator exterrius 
Quadratus femoris 



Gluteus niaximus 
Fig. 104. — Anatomical relations of the hip-joint. 




Fig. 105. — Position of a patient under treatment for fractnre of the 
pelvis, witli compression applied by means of weiglits. There was 
much extravasation around the left hip and left iliac hone, with 
abnormal mobility and doubtful crei)itus, and marked ]iain on 
pressure about the left sacro-iliac joint. The injury was due 
to tlie fall of a lieavy weight on the pelvis. When the patient 
was discharged with a pelvic band of plaster of Paris, the left 
iliac crest was 2 cm. higher than the ri!;'ht one. 



Tab. 49. 




Eig.1 




FAg.2 




Lithinst.v. F. Reiohhold , München 



PLATE XLIX. 

FRACTURES OF THE PELVIS. 

Fig. I. — Severe fracture due to the patient being run over by a 
wagon. In front the pubis is broken on each side close to the 
obturator foramen ; posteriorly the fracture passes on the right side 
just external to the sacro-iliac synchondrosis ; on the left side this 
articulation has given way. The specimen represents the double 
vertical fi'acture of Malgaigne. 

Fig. 3. — Fracture through the acetabulum. The specimen was 
obtained from a lad, aged fourteen, who had been caught in a threshing 
machine. There was a severe wound over the adductor muscles, 
through which the fractured rami of pubis and ischium could be felt. 
Neither bladder nor urethra were damaged. The patient succumbed 
from shock, and the specimens figured on Plate I were also obtained 
at the post-mortem. 

Fig. 3. — Fracture of the ilium, not involving the pelvic girdle. 



FßACTUKES, ETC., ÜF THE LOWEli EXTREMITY. 113 




Kig. io6. — Representation of Nelaton's line, the liip being bent. 




Fig. 107. — Manipulation method for reduction of a dislocation of the thigh 
first stage, showing the flexion of knee and hip to a right angle. 

risks of gangTene and sepsis. Under these circumstances a 
free incision in the middle line should be made into the 
perineeunij which is swollen with extravasated blood. This 
incision should be made over the region of the bulb, and 
especially of the membranous portion, and should, if possible, 
enter the urethra ; but a formal urethrotomy is very difficult 
to execute without the aid of retrograde oatheterism, and 
a supra-pubic cystotomy which would enable this to be done 
can hardly be carried out by the ordinary practitioner, but 
it is at any rate the duty of the latter to make a median 
perinseal incision to prevent extravasation and in anticipation 
of further operative measures. 

The forms which fractures of the pelvis take are many. 

8 



114 CHAPTEU IV. 

Apart from force transmitted tlirougli the spine and tlie 
femora, fractures may arise from antero-posterior pressure, 
as for instance when a cart passes over the pelvis, or a horse 
falls on it. We know from clinical and experimental evi- 
dence that from such a force fractures in the neighbourhood 
of the obturator foramen {i. e. through the ascending rami 
of pubes and ischium) together with a separation between 
sacrum and ilium, or a fracture close to the sacro-iliac 
joint, will probably occur. An exactly similar result may 
occur when the pressure is exerted laterally, though on 
the living subject the violence may be so extreme that we 
may find fifteen or twenty different lines of fracture. In 
examining such a case the surgeons should gently press the 
ilia together, when, if there is a fracture, sharp pain will be 
felt at its site, with sometimes abnormal mobility and crepitus. 
A thorough examination of all bony projections, such as the 
posterior superior spines and the tuberosities of the ischium, 
should be made on both sides, and sometimes exploration 
through the rectum is useful.^ The prognosis depends on 
the injury to the neighbouring parts, and where this is not 
present, recovery is to be expected. 

In the treatment, rest on a water bed with a suitable pelvic 
band form the chief points. If the fracture passes through 
the acetabulum, passive motion of the hip must be carefully 
undertaken in due time. 

Dislocations of the Hip. 

These injuries are rare, and always due to severe force. 
The two chief varieties consist in the forward and backward 
displacement of the femoral head, and in studying them the 
researches of Bigelow on the ilio-femoral or Y-ligament are* 
of much importance ; for unless this ligament be torn, which , 

' From a fall on the trochanter region the head of the femur may be 
driven into the acetabulum so that the pelvis is comminuted. Such an 
injury is difficult to diagnose from an impacted fracture of the neck of the 
femur; the chief signs by which it might be distinguished would seem to 
be tlie marked depression of the trochanter itself (a depression which is 
also very noticeable in thyroid dislocation of the hip) and by the exag- 
gerated crepitus felt on numipulation. Two cases are recorded by Mr. T. 
Holmes, 'Patli. Trans.,' 1887, p. 231. — J. H. 



DISLOCATIONS OF THE HIP. 115 

only occurs in the rarest of cases, the dislocation will always 
conform to one or other of these regailar types. 

A. Backward dislocation at the hip (retro-cotyloid) . — If on 
the dead subject the femur be bent and rotated inwards^ 
whilst somewhat abducted, the back of the capsule becomes 
much stretched. If these movements be carried further, the 
head of the bone may be made to project over the acetabular 
edge and tear the capsule, the ligamentum teres giving way 
at the same time. In this experiment the attachment of the 
Y-ligament forms a fulcrum, and the great length of the long 
arm of the lever, compared with the short arm, accounts for 
the force which is exerted to produce the dislocation. 

We have to distinguish between a dislocation on to the 
ilium and on to tlie ischium; in the first the head of the 
femur rests above the tendon of the obturator internus, in 
the ischiatic dislocation below it. In both cases the dis- 
placement happens when the limb is rotated inwards as well 
as flexed, the flexion being greater in the ischiatic than in 
the iliac form.^ The force is more often applied to the back 

* It has been strongly' contended that in dislocation both of the shoulder 
and the hip the rent in the capsule is situated chiefly or entirely at the 
lower part. Thus Mr. H. Morris states that dislocation of the hip nearly 
always occurs with the affected limb in the position of flexion and abduc- 
tion ; the head of the femur leaving the joint at its lower part travels 
backwards, i. e. on to the dorsum or ischium, if the thigh is rotated in- 
wards, or rather if the acting force tends to turn the thigh in this direction as 
well as to force it out of its socket. Morris ('Med. -Chir. Trans.,' 1892) having 
examined a considerable number of specimens, states that this rule is almost 
without exception. If the dislocation is a direct dorsal one, that is, if the 
rent in the capsule is at the upper or back part alone, it is combined with 
fracture of the cotyloid edge. On the other hand, some writers, including 
the late Sir G. Humphry and Mr. Eve, have disputed this view, contending 
that frequently at the moment a dislocation of the femur occurs the thigh 
is flexed and addueted. It is of interest to note that occasionally one femur 
is dislocated forwards, the other backwards, and I have examined one such 
case (dorsal with thyroid dislocations). With regard to the humerus there 
can be no doubt that the dislocation often happens from a fall or blow on 
the shoulder itself, when the arm is not specially addueted, and the rent in 
the capsule will be opposite the part struck, i. e. usually the anterior 
portion of the capsule. Wlien comparing the hip and shoulder it must be 
remembered that the anterior portion of the capsule in the former joint is 
of great strength, whilst the lower part is the weakest, whilst in the 
shoulder there is no such difference. The matter is by no means of merely 



116 CHAPTER IV. 

whilst tlie femur is fixed^ than vice versa. When the head 
of the bone passes beneath the obturator internus, and the 
gemelli, these muscles may form an important obstacle to 
replacement. 

Sy7}ij)tomf;. — The thigh is rotated inwards and more or less 
strongly flexed and adducted. There may be some short- 
ening made out on measuring from the anterior superior 
spine of the ilium to the lower border of the patella. This 
shortening is greatest in the iliac form, and is especially 
evident when the two limbs are flexed^ still more whilst the 
patient lies on his back, and the pelvis is kept exactly hori- 
zontal. It is most easy to ascertain this when the patient is 
under an aneesthetic. 

The top of the great trochanter is situated above Nelaton^s 
line. The inward rotation, which is present in all the ordi- 
nary cases of dislocation backwards, is absent in a few ex- 
ceptional ones, where the capsule and upper part of Bigelow's 
ligament are very extensively torn. The upward displace- 
ment of the trochanter can also be made out by measuring 
the distance between it and the anterior superior spine on 
both sides with the fingers. It is difficult to make out by 
palpation the displaced head of the femur, especially when 
there is swejling present. Power of active motion of the 
hip is lost. Passive flexion and increase of the adduction 
and inward rotation may be effected, but are painful ; and 
when it is attempted to abduct and rotate outwards the limb 
there is a characteristic elastic resistance felt, due to stretch- 
ing of the Y -ligament. 

The more extensive the range of passive motion and the 
less the inward rotation of the limb, the more certain may 
we be that the capsule and muscles are much torn. 

Treatment. — It has been already noted that for the exami- 
nation of a case of dislocation of the hip, the patient should 
be thoroughly anaesthetised, and the same applies to the 
reduction. 

theoretical importance, for tlie success of Kocher's method of reduction of 
dislocation of the shoulder is said to be lar«,^ely due to the fact that the 
rent is chiefly placed in the lower quadrant, and that by raising the elbow 
to the level of the shoulder the head is brought opposite to this rent.— 
J. H. 



Tab. 50. 




Fig.2 



Fig.3 



LithJtast.v. F. ReichhoM, Miiiubfn 



PLATE L 

Fig. I. — Dislocation of the femui on to the ischium produced artifi- 
cially. The gluteus ma\iinns has been divided in its long axis and 
held aside, and the deepei muscles also sepaiated so that the head of 
the bone can be seen The gluteus minimus and pyriformis are 
clearly seen above the head , the obtui atoi esternns and the quad- 
ratus femoris, part of vrhose fibres were torn, are displayed. The 
great sciatic nerve is clearly seen just to the inner side of the head, 
and close to it the origin of the hamstring muscles from the ttiber 
ischii. 

Fig. 2. — Dissection of the normal hip for purposes of comparison 
(for explanation see Fig. 104). 

Fig. 3. — Dislocation on to the ilium, showing the head placed above 
the obturator internus. 



j3- 



DISLOOATfONS OP THE HIP. 117 

The patient lies flat upon the ground or a hard mattress, 
his pelvis is steadied by an assistant, or in case of necessity 
where no assistance can be had, by the operator's foot 
(naturally with the boot removed). The affected limb is 
then bent at a right angle to the trunk, the knee being also 
flexed to a right angle ; sometimes, if the head is situated 
just behind the acetabulum, simple direct traction upwards 
suffices to reduce it, but in most cases the thigh must be 
abducted and rotated outwards.^ 

The interposed capsule may form an obstacle to reduction, 
which may be overcome by various movements of the hip ; 
occasionally it may be necessary to divide it by incision. I 
have thus succeeded in getting back a dislocation of some 
weeks old in a child with recovery of good mobility. In 
old unreduced cases, resection of the head or even osteotomy 
below the trochanters may be indicated. 

B. Forward dislocation (preecotyloid) . — This form of dis- 
placement is rarer than the backward one ; in it the capsule 
tears at its front part, the head of the bone rests on the 
pubis over the obturator foramen or even towards the peri- 
nteum, the limb is rotated outwards and abducted, the 
degree of flexion varies, being but slight in the pubic form, 
whilst the lower the head is displaced the more will the 
thigh be flexed. If placed over the pubis the head is easily 
felt through the skin, the femoral artery may be lifted up, 
and there may be pain from the stretching of the anterior 
crural nerve. If the head is displaced more downwards, 
flexion and abduction with outward rotation are certain to 
be present. In the differential diagnosis we may distinguish 

1 The author recommends traction with the thigh adducted and rotated 
inwards as the routine, and if this fails abduction and outward rotation, but 
does not give any reason for departing from the practice generally found 
successful, and I have therefore ventured to alter the text slightly. In 
attempting reduction by manipulation of a dorsal or ischiatic dislocation 
there is a considerable risk of flexing the thigh too much and making the 
femoral head travel below the acetabulum into the thyroid foramen, or in 
the case of thyroid dislocation converting it into a dorsal one. Once this 
has occurred the surgeon may find himself much embarrassed by its repeti- 
tion on every fresh attempt. Direct traction in the axis of the thigh 
whilst the bead is brought down will probably succeed in levering it over 
the acetabular edge. — J. H. 



118 



CHAPTKR. IV. 



a fractni^e of the neck by tlie facts that the thigh is shortened 
and rotated outwards, that the elastic mobility is absent, but 
that the limb can be got into position by simple traction, 
whilst it returns into its former position directly the traction 
is removed ; finally other movements can be effected than 
those allowed in dislocation. 

Reduction — In the pubic form direct traction when the 
limb is extended ma}^ suffice, but usually the limb must be 
flexed more or less, and inward rotation followed by adduc- 
tion carried out. Circumduction inwards with simultaneous 
traction on the limb may be required. 




'■%. 1'. '- 

Fi<^. 1 08. — From a remarkable case of old unreduced dislocation 
on to the pubes. The limb was of coui'se considerably short- 
ened, but the man could got about fairly well. The head and 
neck of the femur have become considerably altered in shape ; 
the great trochanter articulated with the anteiior superior 
spine, the lesser trochanter with the ascending ramus of the 
pubes. Copied from Sir Astley Cooper. — J. H. 



Tafc/.ol 



Tab. 52. 




Fk/. 3 a. 




Ei^.1 




Fig. 3 






% I 



I %^ 



Fig. 4 a. 



Lithinsi.v. K. Reinhhold , Müiicln 



PLATES LI AND LH. 

THE DIFFERENT TYPES OP DISLOCATION OF THE HIP. 

In Plate LII tlie corresponding positions of the lower limbs are 
shown. 

Figs. I and i a. — Dislocation on to the ischium. 
Pigs. 2 and 2 a. — On to the ilium. 
Figs. 3 and 3 a. — Into the obturator foramen. 
Figs. 4 and 4 a. — On to the pubes. 



DISLOCATIONS OF THE HIP. 119 

c. Rare forms of dislocation. — Downward displacement 
(infra-cotyloid) is very rare ; in it the limb is strongly flexed 
and slightly abducted. The patient may be able to stand on 
the affected limb as in the case of pubic dislocation. Reduction 
is accomplished by traction on the bent thigh. Upward 
dislocation is also extremely rare ; the head of the bone may 
be felt close to the anterior inferior spine^ the limb is ex- 
tended, rotated outwards, adduoted, and much shortened. 
Reduction by means of flexion and inward rotation. 

We have also to note the occasional complication of frac- 
ture of the femur (neck or trochanter), or of the edge of the 
acetabulum, with a dislocation. As an extreme rarity the 
head of the bone may be driven into the pelvis when the 
acetabulum is broken. This condition is of interest from its 
analogy with fracture of the base of the skull through im- 
paction of the condyle of the jaw.^ 

Fractures of the U'p'per End of the Femur. 

We have to distinguish the following forms : 
r. Intra-capsular fracture of the neck. 

2. Traumatic detachment of the epiphysis of the head. 

3. Extra- capsular fracture of the neck. 

4. Fracture through the trochanter region. 

' Unreduced dislocation of the thigh means, as a rule, permanent and 
grave limitation of mobility in the limb. But this is not always so, foi 
occasionally recovery is almost perfect. Thus in the case of an athletic 
soldier, recorded by H. Morris (' Med -Chir. Trans.,' 1892, p. 106), who 
had a dorsal dislocation with one and a half inches shortening, the knee could 
be made to touch the shoulder, abduction and rotation were extremely 
good, but naturally there was a peculiar gait like that of a case of con- 
genital dislocation. 

When the dislocation is of very old standing, and much loss of function 
is present, an operation may be justifiable. This will take the form of — 

1. An attempt to replace the bone in the socket after dividing and 
holding aside the capsule. This is likely to fail. 

2. Excision of the femoral head. Two successful cases are quoted by 
Morris (loc. cit., p. 105). 

3. Osteotomy of the femur, either above or below the trochanters. In a 
case of old thyroid dislocation (pathological) in a young man with great 
deformity owing to flexion and abduction, I obtained a very good result by 
infra-trochanteric osteotomy. The limbs were ultimately the same length, 
and the patient could walk long distances without difficulty. — J. H. 



120 CHAPTER IV. 

5. Isolated fracture of the great trochanter. 

6. Fracture of the femur just below the trochanters. 

Fractures of the vech are relatively common ; when intra- 
capsular the vascular supply of the detached head is much 
impaired^ especially as in old people the arterial branches 
accompanying the ligamentuni teres are very small^ and the 
upper fragment may form a sort of loose body in the joint. 
When partly extra-capsular the vascular supply for the 
repair of the fracture is much less damaged. In both forms 
indirect violence may be to blame, such as a fall on the 

r ^-ir— ^ 



1 




I 


' 


^L^^ 


/ 


^w^^ 




■^ r 


r 



Fig. 109. — From a ca,se of fracture of the neck of the left femur, 
showing the upward displacement of the trochanter major. 
This is made especially evident by comparing the relative posi- 
tion of the lines drawn through the anterior superior spines. 

knee or the patient tripping up from catching his foot. In 
other cases a fall sideways on to the trochanter major may 
produce impaction of the neck into the spongy bone of the 
trochanter region. The frequency of these fractures in old 
people is due to the rarefaction of the cancellous bone and 
the substitution for it of fat, a kind of osteoporosis which is 
most common in women ; further, the angle formed between 
the neck and the shaft diminishes in some subjects as age 
advances, a circumstance also favouring fracture. 

Pathology. — ^Plntes LIII, LIV, and LV illustrate the chief 
points, Plate LIII showing the typical intra-capsular fracture 
resulting in a false joint ; the detached head being, as n rule, 
fixed to the acetabulum by fibrous or even bony adhesions. 



FRAOTÜRKS OF THE UPP1<]1{. KNI) OF THE FBMÜR, 121 

Plate LIV sliows the more common impacted extra- 
capsular fracture^ after which the amount of callus formed 
may be excessive. It maybe noted that the original impac- 
tion may» disappear owing to the patient bearing his weight 
on the limb too soon^, and a slight degree of shortening may 
thus be converted into a very considerable one. 

Jn nearly all cases of fracture of the femoral neck^ rotation 




" ^''/ '^ ; :.^ 







Fig. no. — Vertical section of the femur to sliow the vascular 
supply of the head of the hone. It will be seen that a bundle 
of small vessels run along the ligamentum teres but do not get 
into the bone, which is supplied by arteries running along the 
reflections of the capsule (the so-called retinacula). Copied 
from Sir Astley Cooper. 

of the limb outwards is a marked symptom. This is due 
chiefly to the fact that the posterior part of the neck is 
weaker than the anterior, and therefore tends to be more 
crushed or impacted (as illustrated in Plate LV, fig. 4). 

Syvcptoms. — One should always think of the possibility of 
a fracture of the femoral neck when an old person, after a 
fall on the knee or side of the body, cannot stand up, and 



122 CHAPTER IV. 

when the injured limb is shortened and rotated outwards. 
In the diagnosis contusions and dislocations of the hip and 
fractures of the pelvis have to be considered. It is hardly- 
possible to mistake the injury for a dislocation (with out- 
ward rotation only a forward dislocation could be possible). 
In the case of fracture the patient cannot raise the limb 
from the bed ; it lies helpless and shortened to a variable 
deg'ree, whilst corresponding elevation of the great trochanter 
above Nelaton^s line can easily be made out. Direct palpa- 
tion of the seat of fracture is difficult, and not of much 
importance unless the great trochanter region is involved. 
The trochanter is displaced nearer the middle line than on the 
normal side, but the determination of this measurement is so 
difficult and uncertain that the point is of little importance 
in diagnosis. Passive motion of the injured limb, although 
painful, can be effected, and crepitus will be felt unless 
firm impaction is present or the fragments much displaced, 
notation of the limb on its long axis takes place on a shorter 
radius than on the healthy side : this will be most marked if 
no impaction exists. In the impacted variety the shortening 
and outward rotation are usually somewhat less, and of 
course crepitus should not be obtained. The history is very 
characteristic when an impacted fracture has occurred and 
the patient has been allowed to get about without proper 
treatment. 

I may illustrate this point by quoting the case of a 
woman, aged seventy-four, who fell from a chair in her room 
on to the hip, but was able afterwards to stand and walk 
with some pain. This happened on the 17th May, 1896, 
and at the beginning of August of that year sharp pain with 
sudden loss of power came on in the hip just as the patient 
had sat down on the edge of the bed. She now became 
bedridden and had to have weight extension applied. It 
will be noticed that in this case the patient had actually walked 
about two and a half months before the impaction became 
loosened. 

Treatment. — ^As the patients are chiefly old and enfeebled, 
attention to improving the general health and careful feeding 
are especially indicated. The gradual onset of hypostatic 
pneumonia is to be feared during the necessary confinement 




Ei^.lb 





Pig. 2 a 

LitkAnsi v. V Reinhhold , l^liiiicltm . 



PLATE LIII. 

INTRA-CAPSULAR FRACTURE OF THE NECK OF THE FEMUR. 

Figs. I a and i h. — False joint witli complete absorption of the neck. 
The two opposed bony snrfaces were smooth and polished, as though 
from arthritis deformans, and many osteophytes have developed around 
them. The chief movement allowed was one in the upward and down- 
ward directions, and this is indicated in the specimen. 

Figs. 2rt and 26 — Impaction of an intra-capsular fractvire. Spe- 
cimen obtained from a woman aged eighty-two. It will be noticed in 
fig. 2rt that the normal contour has been fairly preserved, though the 
neck is sboi'tened, and the great trochanter higher than normal. In 
fig. I h tlie bone is shown in section. The shaft is slightly adducted 
with resrard to the head. 



FRACTURES OF THK UPPER END OF THE FEMUR. 123 

to bed ; frequent chang-es of posture^ &c., should be tried, 
and the patient got up as soon as possible. The impacted 
fractures in the trochanter region unite with exuberant callus, 
whilst the non-impacted fractures of the neck very rarely 
unite by bone at all.^ It need hardly be said that great 
caution should be employed before allowing the patient to 
bear weight on the limb. if the fracture is thought to be 
impacted. In ordinary cases extension and inward rotation 
should be secured with weight extension by means of strap- 
ping. A weight of 12 to 15 lbs. is usually required; if pos- 
sible, an apparatus which allows a certain amount of change 
of position should be employed. 

A splint (made of leather, poroplastic felt, &c.), with which 
the patient may be allowed to get about on crutches, should be 
made use of early. Operative interference, such as fixing the 
fragments by steel nails, can only be justifiable in rare cases. 
Kocher has lately recommended early excision of the detached 
head in intra-capsular cases as the best method. Should this 
be contra-indicated by the patient^s age, weakness, &c., mas- 
sage and gentle passive motion should be begun as soon as 
possible. 

The final result is as a rule not brilliant ; since the surgeon 
has to deal with an old and feeble subject he may be content 
if his patient manages to walk ultimately with the help of a 
stick. 

Traumatic separation of the epipJiysis of the head of the 
femur (see Plate LY, fig. 5). — This is an extraordinarily rare 
injury, contrasting in this respect markedly with the de- 
tachment of the head of the humerus. The explanation is 
to be found in the small size and sheltered position of the 
epiphysis of the femoral head, which is wholly within the 
joint and has no ligament or part of the capsule attached to 

' Firm bony union of fractures of the femoral neck is not so rare as some 
authors would lead one to believe, and may occur even in advanced periods 
of life. In the Royal College of Surgeons Museum (No. 1006) there is a 
specimen showing firm union of an " intra-capsular" fracture of the neck 
and a fracture four inches below the trochanter in the right femur of a man, 
who sustained the first fracture at the age of seventy-three and the second 
a few months later when attempting to get out of bed. He lived to be 
seventy-five. — J. H. 



124 CHAPTER IV. 

it.' The diagnosis and ti-eatment offei^ nothing special to 
note. 

Fracture of fJie trochanter major is usually only part of an 
extra-capsulai- fracture of the neck, but very occasionally 
this promineuce of bone is broken off by direct violence as 
an isolated fracture. The detached fragment is drawn up 
by the glutei, and can probably be distinguished. The 

' The writer must here have forgotten tlie ligamentum teres and some 
bands oE reflected capsule — -tlie retinacula, which are both connected with 
the epiphysis. 

Up to the age of twelve or eighteen months it is possible that the 
mainly cartilaginous upper end of the femur, including the head and great 
trochanter, might be separated from the rest of the bone ; but it has never 
been proved by dissection to have occurred from traumatism during life, 
and experimental attempts on the cadaver have generally failed. In 
children and young adults, however, the clinical evidence (which has been 
lately dwelt on by Mr. Hutchinson in the ' Archives of Surgery ') points very 
strongly to the possibility of detachment occurring exactly at the epiphysial 
line between the head and neck of the bone. The specimen from an 
undoubted case of this has been described and figured by M. Bousseau of 
Paris. The patient, aged fifteen, had been run over by a cart, and after 
his death from shock it was found that the capsule of the left hip-joint 
was torn, and that the epiphysis for the head was detached exactly at the 
epiphysial line. To this solitary case we may add several others derived 
from the lower animals. In the museum of the Royal Veterinary College 
there are two examples obtained from horses, in the London Hospital 
Museum one from a rabbit; these were cases of traumatic detachment of 
the epipliysis. 

That intra-capsular fracture of the femoral neck occurs in young subjects 
has been proved by specimens described by Coulon, Stanley, and otiiers, 
and by two in the museums of the Middlesex and Guy's Hospitals. 

I have collected records of upwards of twenty cases in which the sym- 
ptoms (shortening from half to one and a half inches, eversion of the limb, 
more or less crepitus, alteration of Bryant's measurement, &c.) indicated 
either a fracture of the neck or separation of the epiphysis in patients 
under twenty years of age. Dr. Whitman has lately recorded six other 
examples, and he holds the view that in the majority the lesion is a 
fracture. 

It is onlv necessary here to allude to the numerous cases in which, after 
a wrench of the hip, acute epiphysitis has occuri'ed, and the head become 
thus detached from the neck. Such separation of the epiphysis is, of 
course, secondary to the inflammatory process. In cases of detachment or 
of fracture of the neck in young subjects which are primarily due to the 
accident, bony union appears to follow treatment in nearly all of them. In 
one, however (recorded by Mayo Robson), a false joint seems to have been 
formed. —J. TI. 



Tab. 54. 





Fig.ib 



Eig-lcL 





Eig.2a^ 



Fig. 2b 



Litli.Änyl .V. Y. Reichhold . Miiiicteii 



PLATE LIV. 

EXTRA-CAPSULAE. FRACTUKE OF THE FEMORAL NECK. 

Figs. I a and i h sliow tlie impaction of the neck into tlie trochanter 
region, the former being placed almost at a right angle to tlie shaft. 
In fig. I h the normal outline of the femur is indicated, so that the 
degree of shortening can be estimated. 

Figs. 2 a and 2 h. — Old estra-capsular impacted fracture, the acci- 
dent having occurred five years before death. The patient, a woman 
aged eighty-two, was the same from whom tlie specimen of intra- 
capsular fracture sbown in Plate LIII, figs. 2 a and 2 h, was obtained. 



Tab. 55. 





Ei^.1 



Ei^.2 




"'■'i-y^:. 







FigJ 





LlthJnsl.v. F. Reichhöld , Münchea . 



PLATE LY. 

Figs. I and 2. — Anterior and posterior views of a specimen of 
impacted fracture of the neck. 

Fig. 3. — Section in the axis of the neck of the same preparation. 

Fig. 4. — Diagram illustrating the great impaction that has occurred 
at the back. 

The above figures illustrate the outward rotation of the femur which 
occurs in these cases. 

Fig. 5. — Section to show the epiphyses of the femoral head and 
great trochanter. 



l''RACTÜi;ES OK THE SHAFT OF THE FEMUR. 125 

obvious treatment is to fix it in position by means of a steel 
needle^ approximation being favoured by abduction of the 
thigli. 

Fracture immediately helow the trocti anters. — This variety 
may be due to direct or indirect violence^ and may take the 
form of a transverse or more commonly a very oblique or 
vertical fracture ; it occurs in adults whose work exposes them 
to the risk of severe accidents. There is no predisposition 
to this accident in old age. 



/J 



Pig. III. — The specimen wliich is figured in Plate LVI, fig. i, is 
here seen from the outer side; tlie upper fragment is somewhat 
flexed ; the shaft is displaced upwards and forwards. 

Sympto'iiis. — Apart from those common to all fractures^ 
we have to note that the upper fragment tends to be strongly 
flexed and abducted^ owing to the contraction of the ileo- 
psoas and glutei. When the limb is rotated it will be found 
that the trochanter does not move with the rest of the femur. 

Fractures of the Shaft of the Femur. 

These are very frequent, especially just above the centre of 
the bone; whilst sometimes due to twisting of the limb (or other 
indirect force), they are more often the result of direct violence. 
They are common amongst children, and the result in them is 
usually excellent, since the periosteum prevents displacement 
occurring. In adults this, however, is usually marked, since 



126 



OHAPTEK, IV. 



the line of fracture is often oblique and the contraction of 
the muscles is difficult to overcome. Abnormal mobility and 
crepitus are almost constant^ and if the latter is not noticeable 
it may be inferred that the soft parts are interposed^ so that 
it becomes necessary to elicit it in order to guarantee good 
union. Shortening is also readily made out by the usual 
measurements. 

Fractures above tlie centre of the bone often result in 
angular deformity, the upper fragment being flexed and 
abducted by the ilio-psoas and glutei, whilst the lower frag- 
ment is drawn upwards by the adductors^ &c. Sometimes 
a false joint is formed (see Fig. 113), and occasionally union 
takes place with bending backwards of the femur (see 
Fig-. 112). 



Fig. 112. 



Fiu. 113. 





Fig. 112. — Fracture in the middle of the thigh, united with 
backward bending. Annexed is a sketch of the bone to show the 
displacement. 

Fig. 113. — Fracture just below the centre of the right femur 
with a false joint and excessive overlapping. Operation : resec- 
tion of the ends of the bone, with as much extension of the limb 
us could be obtained. Ilesult : firm union. 



FKACTUliES Oe THE SHAFT OP THE FEMUR. 



127 



Treatment. — This lias become quite simple since the in- 
troduction of strapping- and weight extension ; at the same 
time it must not be thought to requite but little care in its 
application ; for example, the bands of strapping must be 
applied with skill so as to exercise no injurious pressure, and 
they must be strong enough to sustain a weight of 20 to 25 lbs. 
Yolkmann's apparatus, which allows the foot-piece to slide 
according to the weight (see Figs. 115 and 116) is useful; 
counter- extension is best obtained by raising the foot of the 
bed, whilst the sound limb gets a purchase against a block 
(see Fig. 115). 




Fig. 114. — A simple form of sliding foot-piece for weight extension, 
wliicli can readily be improvised. 




115. — Fracture of tlie femur treated with weight extension, &c. 



With the patient so placed the site of fracture is of course 
accessible to palpation, but owing to the thickness of the 
muscles the exact position of the fragments cannot alwaj^s be 
made out by the fingers, and hence careful measurement of 
the length of the limb should be made from time to time. 
If there is any doubt as to the symmetrical position of the 



128 



CHAPTER IV. 



two limbs^ that is if the injured limb is really abducted, this 
fact can be made out after the manner shown in Fig. ii6. 




. X 




Fig. 1 1 6. — Position in whicli measurements as to the length of 
the limb after putting up a fracture of the femur should be 
made. The sound limb is brought into symmetrical position 
with regard to the pelvis. 

Sometimes it is found that simple extension does not suffice 
to correct the displacement. The rule should then be fol- 




Fig. 117. — Weight extension applied to the thigli in a case where 
contraction of the knee prevented its application to the leg. 



FRACTURES OP THE SHAFT OF THE FEMUR. 



129 



lowed that the lower fragment should be brought into the 
same position as the upper one ; thus, for instance, it may be 
necessary to flex and abduct the femur, and apply the weight 
extension in this position, whilst lateral traction by weight 
may be required to limit the abduction of the upper fragment 
(see Fig. 1 18). 




Fig. ii8. — Weight extension for fracture of the left femur, with 
counter-extension and lateral traction. 

In children we can strongly recommend the use of vertical 
extension (Figs, iig and 120). The fear lest this elevation 
of the limb should cause angemia and imperfect formation of 
callus, cannot have much foundation, and if necessary such 
'tendency to anaemia of the limb may be corrected by an 
india-rubber bandage applied above the fracture as shown in 
Fig. 6.^ 

In case of fracture amongst newly-born or quite small 
children the most simple and best method of treatment con- 

1 This passage has been strictly translated, but it is doubtful if the 
vertical position of the thigh has any advantages, whilst it is certain that a 
condition of venous stasis, such as would be produced by the india-rubber 
bandage, could not possibly be of benefit. In practice it is found that the 
ordinary box splint, both from the surgeon's and the nurse's point of view, 
is preferable to the "gallows splint," and certainly the methods shown in 
Figs. 119 and 120 cannot be efficient in securing fixation and rest at the 
site of fracture unless German children are much more docile than English 
ones. — J. H. 



130 



CHAPTER IV. 




Fig. 119. — Vertical weiglit extension applied to a child with 
fractured femur. It will be noticed that the pelvis is tilted by 
the extension. 




Fig. 120. — Vertical weight extension with lateral traction to cor- 
rect flexion of the upper f vfigraent. 



Tab. 56. 



f i^ 





Eig.3 




Lit!i..^tb1 ,v. F, Hcii'lilioM , Münr.hPii , 



PLATE LVI. 

VARIOUS FEA.CTUE.es OF THE FEMUE. 

Fig. I. — Posterior view of an oblique fracture below the trochanters, 
united with excessive formation of callus. 

Pig. 2. — Oblique fracture of the upper half of the femur, due no 
doubt to violent torsion of the bone. 

Pig. 3. — Oblique fracture in the lower half of the femur, with lateral 
displacement and overlapping, united with much callus. 

Pig. 4. — Transverse fracture in the lower half of the femur, united 
with much overlapping. The displacement of the lower fragment is 
that which is prone to occur in fractures just above the condyles. 



FRACTÜl^ES OP THE T.OWKR END OP THE PEMÜIJ. 131 

sists in fixing the thighs, strongly flexed upon the abdomen^ 
by means of a broad band of strapping passed round the 
back and thigh. 

Plaster-of -Paris bandages find their use in 
the treatment of fracture of the femur when 
it is necessary to get the patient up very soon^ 
in the case of the supervention of delirium 
tremens, or in treating young children. The 
principle of the ambulatory treatment of frac- 
tures of the femur depends upon the apparatus 
taking its bearing poiut from the tuberosity of 
the ischium, so that the lower limb hangs 
freely in it, and extension may be made whilst 
the support is applied ; for this purpose I have 
found nothing better than the splint devised 
by the Liverpool surgeon H. 0. Thomas (see 
Fig. I2i). The simplest form of this splint 
can be made by any blacksmith and saddler. 
With the use of Thomas's splint it is practicable 
to get most of the cases about within three to 
four weeks without any detriment to the union, 
or to the general condition of the patient. 
To attempt to apply this treatment, however, 
from the day of the accident is dangerous, and 
it can rarely be necessary or advisable to get „^'^' 'f^' 
the patient up before three or four weeks have splint, 

elapsed. If the fracture is situated in the 
upper third of the bone, owing to the marked tendency to 
displacement the ambulatory treatment cannot be recom- 
mended. If a fracture of the femur has united with marked 
deformity, osteoclasis or osteotomy should be performed, and 
with the subsequent use of strong weight extension the 
shortening can be in great part overcome. 

If, on the other hand, non-union has resulted, and a false 
joint is present, an appropriate operation may prove suc- 
cessful. 

Fractures of the Lower End of the Femur. 

(See Plates LVIII, LIX, and LXIII.) The epiphysial 
line crosses the lower end of the femur, first above the most 



132 CHAPTER IV. 

prominent points of tlie condyles (see Plate LIX). We have 
to distinguish between {<() fracture of the femur just above 
the condyles, usually oblique; {h) true separation of the epi- 
physis ; (c) oblique and T-fractures of the condyles ; and [d) 
detachment of parts of the articular surface (Plate LXIil, 

%• 0- 

The number of fractures of the lower end of the femur is 

very much less than that of cases of fracture of the shaft above. 

A. Supra-condylar fractures. — (See Plate LYIII.) As a 
rule we have to deal here with a transverse, but occasionally 
an oblique fracture, and sometimes with a spiral or longi- 
tudinal one due to twisting of the bone.^ 

When the fracture is transverse or somewhat oblique, the 
displacement of the lower fragment is very typical, the 
powerful gastrocnemius tending to flex this portion of the 
bone towards the popliteal space, so that the upper fragment 
rides over the lower. In the diagnosis we have not only the 
shortening of the thigh, crepitus, and abnormal mobility, but 
the projection of the displaced fragment to help us. The 
knee-joint is often involved as a result of the injury. In 
the treatment the apparatus must be applied with the patient 
fully angesthetised. Weight extension with direct pressure 
on the displaced lower fragment is employed. If the 
tendency to displ.M cement is very maTked, a suitable apparatus 
may be applied with the knee bent. One must not forget 
that the pressure of the displaced lower fragment upon the 
popliteal vessels and nerve may produce dangerous sym- 
ptoms, and even gangrene of the leg." 

' It lias been fuUj established, especially by the work of French sur- 
geons, tbat spiral fractures may extend the i^reater part of the length of 
such bones as the femur and tibia, and that owing to the slightness or 
absence of displacement such spiral fractures have been thought to be 
rarer than they actually are. The general use of radiography will pro- 
bably reveal, in many cases where a violent twisting force has been applied 
to a limb, the unsuspected presence of a spiral or longitudinal fissure. It 
may occur at all ages, even in early childhood, and is of considerable 
importance from the possible implication of an adjacent joint and from the 
crushing of the medullary tissue (risk of fat embolism, &c.). For an 
interesting review of the subject see H. Morris, ' Holmes's System of 
Surgery,' vol i, pp. 102 1 (femur) and 1044 (tibia). — J. H. 

2 It is svu'prising that the writer dos not allude to the great value of 
division of the tendo Achillis in these cases. Weight extension can hardly 



Tab. 57. 






Eig.2 



Eig.2cv 



Lilh./\nst.v. F. Reichhold , München . 



PLATE Lvii. : ,; 

FEACTUEE OF THE FEMUE ABOVE ITS CENTEE — TYPICAL 
DISPLACEMENT. 

Fig. I. — Dissection showing the part played by the ilio-psoas 
muscle in producing flexion and abduction of the upper fragment. 

Fig. 2. — Fracture of the right femur united with deformityj from a 
boy aged twelve. One observes the shortening of the right thigh 
causing obliquity of the pelvis, and the angular projection at the point 
of union. 

Fig. 2 «. — Condition of the same patient after treatment. The femur 
was again fractured (by the osteoclast), and the thigh kept strongly 
flexed and abducted with weight extension, so as to prevent a recur- 
i'ence of the deformity. It is now seen to be straight, and the shorten- 
ing to be diminished. 



Tab. 58. 




Fi^.1 



LithJnsi.v. F. Reiclihöld, München 



PLATE LVIII. 

TYPICAL DISPIiACEMENT OF THE LOWER FRAGMENT IN A 
SUPRA-CONDYLAR FRACTURE. 

Fig. I. — Dissection of an ai'tificially produced specimen of supra- 
condylar fracture, viewed from the inner and back aspects. The close 
proximity of the popliteal vessels, particularly the artery, to the sharp 
edge of the lower fragment, which is supposed to be tilted backwai'ds 
by the calf muscles, is well seen, and hence the possible danger of 
gangrene of the leg. In fig. i a the bones alone are represented. 



FKAÜTÜRES OF THE LOWIfR END OP THE FEMUR. 133 

B. Traumatic sejyaration of the lower ep!phya-is. — This 
injury is rarely observed, since the epiphysial disc is a very 
broad onO;, and on account of the small height of the epiphysis, 
great violence is nece.-sary to detach it. For the most 
part the displacement tends to be the same as that of the 
supra-eondylar fracture, but the periosteal sheath may prevent 
any displacement occurring. 

Sometimes the epiphysis travels forward as shown in 
Plate LIX, fig. 4. This will depend upon the kind and 
direction of the acting force. There is nearly always extra- 
vasation of blood into the knee-joint. The symptoms include 
increased girth of the knee, tenderness over the epiphysial 
line, soft crepitus, abnormal mobility, especially felt when 
adducting or abducting the leg, and sometimes pronounced 
displacement. 

Treatment. — After careful reposition under an angesthetic, 
weight extension or a long splint is applied.^ 

do good, whilst the lower fragment is persistently tilted backwards, a con- 
dition only to be overcome by putting up the limb with the knee flexed, or 
by dividing the tendo Achillis. 

In fracture of the femur towards the lower end the femoral artery may 
be damaged by either fragment, and its coats so bruised or torn that 
thrombosis with gangrene of the leg may result. Possibly when the frac- 
ture is put up there are few signs of such a serious injury having occurred ; 
the absence of pulsation in the tibial vessels being of course a most suspi- 
cious symptom. A good example of injury to the femoral artery in • 
Hunter's canal in the case of a simple fracture is recorded by Mr. Ariiott 
('Path. Trans.,' 1868, p 347).— J. H. 

^ There is no epiphysis of so much importance in practical surgery as the 
lower epiphysis of the femur. The grave results that have often followed 
its detachment, including injury to the popliteal vessels, suppuration 
involving the knee-joint, and arrest of growth, have led surgeons from the 
time of Sir Charles Bell to devote special attention to it; and I have 
collected records of no fewer than seventy-five cases, of which ten have not 
previously been published. The anatomy of the epiphysis is so well known 
that it need hardly detain us. We may only recall the facts that the 
epiphysis includes the whole articular surface, and that its separation must 
generally imply injury to the synovial membrane, that the adductor 
tubercle is placed exactly at the upper limit of the epiphysis, and that both 
heads of the strongest muscle in the leg — the gastrocnemius — are attached 
to the latter in great part. Hence the marked tendency to backward 
rotation of the epiphysis in cases of complete separation, and the necessity' 
for the use oF an anaesthetic before attempting reduction. Theoretically 



rSy. ■CHAPTER IV. 

c. Obliqite and T-fradures of the condyles. — In these cases 
the joint is always involved. One or other condyle may 

we might expect separation to occur even beyond the twentieth year; out 
of fifty cases three of the patients had attained that age, the average being 
ten years. The remarkable breadth of the femur at the epiphysial level 
and the great strength of tlie periosteum are circumstances which lessen 
the frequency of this accident. On the other hand, the attachment of the 
gastrocnemius, the popliteus, and the exceedingly strong ligaments of the 
knee, almost entirely to the epiphysis, favour its occurrence when a sudden 
wrenching force is brought to bear upon the leg. And it is nearly always 
a complicated and very violent force that has caused the separation of this 
epiphysis, such as hyper-extension with twisting or traction. Direct vio- 
lence may suffice when the knee is run over, and it is remarkable how many 
cases have been due to the leg getting caught in the spokes of a wheel. 

When experimenting on the bodies of young children (chiefly by abduc- 
tion or adduction of tlie extended knee), I found — 

1. That if the thigh were held high up, the femur usually broke at its 
narrow central part. 

2. That if the lower third were firmly grasped, the epiphysis was usually 
separated. 

3. When separation occurred the epiphysial disc almost always remained 
with the epiphysis, both heads of the gastrocnemius also remaining attached 
to it, and that the periosteum was extensively stripped from the lower 
third of the femur. 

4. It was far easier to separate this epiphysis than to rupture the liga- 
ments of the knee, or to break the shaft in its lower third. 

The latter deduction has an important bearing upon the expediency of 
performing osteoclasia for genu valgum — an operation largely advocated in 
France, and advised in certain cases by such authorities as Macewen and 
Ogston (who has performed it over thirty timesj. 

Now no surgeon would endorse this proposal if there were decided risk of 
detaching the epiphysis, with possible or probable arrest of growth. The 
dangers attending an aseptic division of the femoral shaft are as nothing 
compared with ultimate shortening of the limb to the extent of four, 
three, or even two inches. Putting aside the experiments on the dead 
subject, the following ease sufficiently proves the truth of ray contention. 
A distinguislied Fi'ench surgeon, M. Delore, a great advocate of osteo- 
clasia, and who denied the risk of separation of the epiphysis in this opera- 
tion, performed it on both sides on a child aged seven. The patient died 
of measles three weeks later, and M. Barbarin had the curiosity to dissect 
the limbs. On both sides the femur had given exactly at the epiphysial 
disc. Chauvel records an example of separation of the epiphysis in the 
attempt to straighten an ankylosed knee ; Callender in flexing a stiff knee ; 
Volkinann knew it occur three times during the surgeon's manipulation of 
children affected with old hip disease. As is the case with the lower 
epiphysis of the radius and the upper one of the humerus, separation is 
remarkably clean, occurring exactly at the epiphysial disc, and a division of 



Tab. 59. 








F^l.1 




Eig.S 




Eig.2 




Ftgh 



LitltAnst.v. F PjeicWidld, München 



PLATE LIX. 

Figs. I and 2. — The epiphyses about the knee-joint in a boy aged 
seven are shown in transverse and antero-posterior section. 

Fig. 3. — Side view of the lower end of the femur, showing its 
epiphysis. 

Fig. 4. — Traumatic separation of the lower epiphysis with backward 
projection of the diaphysial end. (From specimen in R.C.S. Museum, 
London.) 

Fig. 5. — Oblique fracture separating the inner condyle of the femur 
(after Anger). 



FKACTUKES OP THE LOWim END OE THE FEMUR. 135 

be broken off, or a T-fracture produced exactly analogous to 
that of the lower end of the humerus. 



the condyles by a vertical split is a rave complication. The epiphysis may 
be completely separated, and yet retained in place by the periosteum ; how 
often this happens without being diagnosed we can only surmise. 

When the diaphysis is forced through its sheath the varieties of dis- 
placement are many, though in the great majority of cases the epiphysis is 
carried forwards, and the danger of stretching the popliteal vessels over 
the broad diaphysial end is only too obvious. It is probable that in many 
of these cases the periosteum in front is not torn. Next in frequency to 
the displacement forwards of the epiphysis comes a lateral one, especially in 
the outward direction, sometimes so extreme that the leg and thigh form a 
right angle when seen from in front, or the deformity may resemble that 
of severe genu valgum. The epiphysis may be rotated on itself as well as 
laterally displaced, and in one remarkable case operated on by Mr. Atkin- 
son, of Leeds, it was displaced right in front of the diaphysis, and so 
twisted that one condyle lay vertically above the other. In one reported 
by M. Trelat, union occurred with the epiphysis rotated through 90° on a 
vertical axis. 

In order to explain the frequency with which displacement has been 
allowed to remain, or with which a wholly wrong diagnosis has been made, 
we must remember that the knee-joint may be distended with blood and 
synovial fluid, and there may be much swelling of the soft parts at the 
time the patient is seen by the surgeon. Not infrequently the diaphysial 
end has been mistaken for the condyles and a dislocation diagnosed, even in 
compound cases. One thing is, however, certain, that a correct knowledge 
of the pathology of separation of this epiphysis would have saved the 
patient and surgeon from many a disastrous mistake. The gravity of the 
lesion is best shown in an analysis of recorded cases. Taking first those 
uncomplicated by wound, out of 28 cases 16 were got into good position 
and recovered with very useful or perfect limbs (the possibility of ultimate 
shortening is not now considered), whilst of the remaining 12 in which 
perfect replacement was not obtained, 6 were followed by sloughing or 
suppuration. In 4 of these amputation had to be performed, i recovered 
after excision of the knee, and i after resection of the diaphysial end. In 
one case a popliteal aneurysm formed twenty years after, and led to ampu- 
tation. The remaining cases recovered with more or less useful limbs, the 
displacement persisting. The cases complicated from the first with wound 
and more or less protrusion of the diaphysis gave still less favourable results. 
Out of 30 cases, 4 died from shock, &c., in 8 reduction was more or less 
effected, with 4 subsequent amputations and 3 deaths from pyaemia. The 
remaining case recovered after suppuration and some necrosis — a truly 
dismal record. In 13 cases amputation was performed soon after the 
injury, with at least 3 deaths (in one the limb was removed at the hip. 

joint). 

In favourable contrast to this list, which is anything but creditable to 



136 CHAPTER IV. 

Diagnosis. — There is increase of width at the knee^ pain 
on pressure about the condyles, lateral mobility with crepitus^ 
effusion of blood into the knee^ and the sharp projections of 
bone may be felt. 

Treatment. — -Since the injury may result in a kind of genu 
valgum or varum, great care must be taken in putting up 
the fracture ; weight extension is best employed with com- 
pression of the joint (if necessary aspiration), and an early 
commencement of massage and passive motion. 

D. Fracture of j)arts of the articular surface. — Excluding 
rare cases in which the attachment of either lateral ligament 
is dragged off with dislocation of the knee, we hare to 
notice detachment of pieces of the cartilage-covered con- 
dyles. These are jDurely intra-articular injuries, which are 
dealt with later. 

surgery, are the cases in which the protruding end of the diaphysis was cut 
off and replacement effected, five in number, all of which recovered with 
useful limbs. It may he said that after resection of the end of the protruding 
diaphysis all growth at the affected part will cease. This is by no means 
certain, and the following case, proving the contrary, is of such interest 
that a brief quotation will be excused. 

I. A boy, aged eight, in climbing beliind a carriage, had his right leg 
caught in the wheel. When examined by M. Delens the diaphysis pro- 
truded through a wound on the outside of the popliteal space. Prolonged 
efforts at reduction under chloroform failed on two occasions, but after the 
end of the bone had been sawn off replacement was easil3r effected. At the 
end of a fortnight the splint had to be removed on account of an abscess 
forming; this was drained and slowly liealed. At the end of fourteen 
weeks good union had occurred, but with some stiffness of the knee and 
4 cm. shortening. He was repeatedly examined during the next ten years, 
and at the age of nineteen the joint was freely moveable, and the short- 
ening amounted only to 9 cm. This proves that a considerable amount of 
growth had occurred at the lower epiphysial disc, since the failure amounted 
only to 5 cm. in the ten years. 

Treatment. — It has been noted that the most common displacement is 
that of the epiphysis forwards and the diaphysis backwards into tbe popli- 
teal space. In order to efft'ct reduction complete anaesthesia should be 
induced, and the knee fully flexed so as to make the heel touch the buttock. 
It is surprising with what comparative ease the epiphysis slips back into 
place by this method. The limb should be kept flexed by means of a 
bandage without the use of a splint, and simply resting on a pillow for two 
or three weeks, and then gradually brought down to the extended position 
by means of a Macintyre splint, — J. H. 



Tab. 60. 




Fig.k 



Fig.3 



lithJnsi v. f. ReifiUioM , München . 



PLATE LX. 



DISLOCATIONS OF THE PATELLA. 



Fig. I. — Dissection of an outward dislocation of the patella, tlie 
articular surface of the latter facing directly the outer condyle. 

Fig, 2. — Dissection of a vertical dislocation of a patella ; in fig. 3 
the latter bone is completely twisted round. 

Fig. 4. — View of outward dislocation of the right patella from a man 
aged twenty-nine. The knee is strongly flexed, and the projection of 
the patella at its outward side is well seen. 



DISLOCATIONS OF THE KNEK AND OE THK FATliLLA, 137 



Disldcatiuiis of the Knee. 

The leg may be dislocated /or (oart^.s- during hyper-extension, 
with rupture of the lateral and crucial ligaments, hachwards, 

Fig. 122. Fig. 123. 

1 
■i 



Fig. T22, — Forward dislocation of the leg. 
Fig. 123.: — Backward dislocation of the leg. 

and laterally in either direction. In all these varieties, which 
are extremely rare, the condyles of the femur can be felt more 
or less plainly in their abnormal position. Owing to the great 
force which is necessary to produce these dislocations, it is 
readily understood that the injuries may be complicated ; 
injury to the popliteal vessels and persistence of the disloca- 
tion may lead to gangrene of the leg, and the knee-joint is 
invariably much damaged and certain to inflame. Reduction 
is, as a rule, easily accomplished by traction and by direct 
pressure. 

Dislocations of the Patella (see Plate LX). 

The patella is not firmly fixed at its sides, being only a 
sesamoid bone developed in the quadriceps. Nevertheless it is 
but rarely dislocated, and most of the examples are in the 
outward direction. This is favoui-ed by the normal position 
of the patella, which rests more against the outer than the 
inner condyle, especially if there is a tendency to genu 
valgum. The dislocation is incomplete if the joint surfaces 



138 CHAPTER IV. 

remain partially in contact^ and complete when the patella 
rests wholly on the outer surface of the condyle. The dis- 
location may occur when the knee is extended^ when the 
patella rides directly over the border of the femoral condyle^ 
perhaps from strong contraction of the quadriceps^ or during 
flexion when the bone slides in the groove between the femur 
and the tibia. The displacement is then probably due to a 
force acting directly on the bone from the inner side^ as for 
instance from a blow against the knee of a rider. The 
diagnosis is easy^ and reduction is effected by direct pressure 
with the knee extended and the hip bent, so as to relax the 
quadriceps.^ 

A vertical dislocation of the patella happens when the 
knee-cap is twisted through an angle of 90°, so that its 
border rests in the groove between the condyles. One 
speaks of an inward and an outward displacement according 
to whether the cartilaginous surface is directed towards the 
inner or the outer border of the joint. The former is 
slightly the more common. The injury usually occurs from 
direct violence, but is said to occur sometimes from muscular 
action. The position of the patella is readily felt. The 
bone may be completely twisted through an angle of 180°, 
so that its joint surface faces forwards. This injury is ex- 
tremely rare, and its diagnosis may be attended with diffi- 
culty. 

Fractures of the Patella (see Plates LXI and LXII). 

These are far more common than examples of dislocation 
of the bone, and are chiefly observed amongst male adults 
under fifty years of age. The patella, like the rest of the 

^ Dislocation of the patella may become habitual in some subjects, and 
cease to cause any discomfoit when it occurs. A woman under my care for 
another complaint dislocated her right patella on to the outer surface of the 
outer condyle every time she bent the knee. Sir Astley Cooper mentions a 
similar case (but symmetrical) in a girl who had been brought up as a street 
dancer (Cooper, ' Fractures and Dislocations,' p. 8). Contortionists and 
others who have habitually stretched their ligaments during early child- 
hood provide examples of this recurrent dislocation ; as also do those who 
have had the ligaments relaxed by long-continued distension of the knee 
from synovitis, — J. H. 



Tab. 61. 




Euf.2 



x' '\ 



Fig.3 




•?^ 




>../ 



Ki^.1 



W!^^ 



Lühinst.v. F Reiohhold, Miinclmi 



PLATE LXI. 



FRACTUEE OF THE PATELLA. 



Fig» I. — Specimen of a complete transverse fractvire of the patella 
with, extensive rent of the lateral expansion of the quadriceps. The 
fibrous aponeurosis covering the front of the patella projects between 
the bony surfaces in shreds. 

Figs. 2 and 3. — Transverse fractui-e of the patella without any tearing 
of the lateral expansion, and hence with no separation of the frag- 
ments. 



Tab. 62. 






Ei^.3 




r^LQ-S 




E^/2 



ütbJSi»>-uF.B«ii(äM«)M, MüfldsRi. 



PLATE LXII. 

FRACTURE OF THE PATELLA. 

Fig. I. — ^Tlie right leg of a man witli old transverse fracture of tlie 
patella united by fibrovis tissue ; a deep groove is seen between the 
fragments. 

Fig. 2. — A young man with symmetrical fracture of the patella from 
a fall on to both knees. Eight weeks after the injury massage of the 
limb was begun, and the drawing shows that the patient was sub- 
sequently able to raise one limb from the bed, and maintain it in a 
position of almost full extension ; this in spite of the marked separa- 
tion between the fragments. Since, however, no further improvement 
was likely to take place, I performed the operation of suture on both 
öides with favourable result. 

Figs. 3 and 4. — Specimens of transverse fracture of the patella 
united by bands of fibrous tissue (from the R.C.S. Museum). 

Fig. 5. — Specimen of stellate fracture, the fragments being bound 
together by callus, with hardly any displacement. 



PRAOTÜRES OF THE PATELLA. 139 

knee region^ is mucli exposed to injury. It may break 
from direct violence, due to a fall on to the knee or the 
impact of a heavy weight. These direct fractures tend to 
take a stellate form, the bone being splintered in more or 
less radiating lines, the fragments remaining as a rule close 
together. From direct violence also we may have an 
oblique, a longitudinal, or a transverse fracture. 

The fractures from indirect violence include those due to 
muscular contraction. It is a popular saying that a drunken 
man in falling seldom or never breaks his knee-cap, since he 
falls like a sack to the ground. Under ordinary circumstances 
in falling one makes consciously, or as a reflex act, a sudden 
contraction of the quadriceps muscle which fixes the patella, 
and may fracture the bone over the end of the femur as the 
knee is bent. Thus results a transverse fracture across the 
centre, or somewhat below this point. No doubt the size 
of the patella, which varies in different individuals, and its 
degree of fixation, are of importance in the production of a 
fracture. As a rule the strong aponeurosis in which the 
patella lies is extensively torn in indirect fracture, more so 
than in that by direct violence, unless in the latter form the 
knee is forcibly bent after the bone has given way. On the 
amount of this tearing of the lateral aponeurosis largely 
depends the degree of sepai^ation of the fragments. (Com- 
pare Plate LXr, figs, i and 2.) 

The proportion of indirect fractures has been over-rated ; 
Bahr estimates it as only about 20 per cent., though the 
grounds for determining this are not very certain. The 
force which leads to an indirect fracture of the patella might 
produce instead rupture of the quadriceps tendon or of the 
ligamentum patellae, but neither of these are nearly so 
common. The symptoms are very simple if the fracture 
runs through the middle of the bone, and is attended with 
separation of the fragments. Since the bone is embedded 
in the joint capsule the injury necessarily involves an 
opening into the joint with extravasation of blood therein. 
This extravasation of blood may completely fill the joint. 
In recent cases, as a rule, one can bring the fragments 
together and produce crepitus. If only a small piece of the 
patella is torn off, and especially if the periosteal investment 



140 CHAPTiilE IV. 

of the bone is fairly intact^ the diagnosis may be rather more 
difficult. However^ on careful examination^ lateral move- 
ments of the fragments^ alike in recent and old cases, can 
almost always be obtained. 

The prognosis of fractures or the patella depends chiefly 
upon the kind and severity of the injury (whether transverse 
or stellate fracture^ and whether it is accompanied by ex- 
tensive tearing of the lateral part of the aponeurosis), and 
upon the nature of the treatment. The fracture from direct 
violence as a rule gives the best result. 

Since after a fracture of the patella the strength and in a 
less degree the mobility of the knee is often permanently 
diminished, the impairment in capability for working must 
depend to a considerable extent upon the patient^s occupa- 
tion. Persons with some light occupation in which, for 
instance, they have mainly to sit at their work, are but 
slightly incapacitated, and I know officers in the army who 
can carry out their duties in spite of ligamentous union of 
such fractures. Working men as a rule suffer considerably 
in their occupation from fractures of the patella. Even 
though the power of extension is completely, and that of 
flexion nearly completely recovered, the knee-joint and lower 
limb remain in most cases weaker, and less fitted for active 
work.^ 

Bahr found in examining forty-four old cases of fracture 
of the patella (which averaged four years from the date of 
injury), that in forty-two some weakness remained, and he 
estimated this impairment *at about 35 per cent, of the 
working power. 

1 It seems impossible to predict the final amount of usefulness o£ the 
limb in a case of fractured patella which unites with marked separation of 
the fragments. The following two cases illustrate this well. 

1. A man aged 17. Fracture resulting in nearly three inches of separa- 
tion, and of course wasting of the quadriceps. When examined a few years 
later the limb was so useful that he had recently walked from London to 
Brighton in a day. 

2. A woman broke her right patella at the age of fifty, with the result of 
three inches separation between the fragments. When examined eighteen 
years later she had no power of extending the knee, had been obliged to 
walk with crutches ever since the accident, and considered the limb prac- 
tically useless. — J. H. 



FRACTURES OF THE PATELLA. 141 

Tieatment. — With no other fracture does one observe so 
many instances in which with wide separation very fair 
function of the limb is retained^ and on the other hand so 
many in which with excellent position of the fragments 
severe and persistent limitation is present. This no doubt 
depends largely on the condition of the quadriceps muscle^ 
which in many cases shows signs of marked atrophy^ and 
this atrophy may first come on some little time after the 
injury. The explanation of the atrophy is partly from pro- 
longed disuse^ but still more from reflex influence of the 
spinal cord centre. To counteract this tendency it has been 
lately proposed that in the treatment daily massage of the 
muscle should be carried out, the direction of the rubbing 
being always towards the knee, which is of course kept ex- 
tended whilst the hip is flexed. Although undoubtedly 
useful, this measure must yet be considered as a somewhat 
one-sided treatment, and it should certainly not prevent the 
attempt to keep the fragments closely in contact. The 
causes for the unfavourable results after healing of fractures 
of the patella are multiple. The contraction of the quadri- 
ceps, the atrophy of this muscle, the effusion of blood into 
the knee-joint, which separates the fragments, the low degree 
of vascularity of the patella and its slight tendency to form 
new bone must be mentioned. Of still greater importance is 
probably the interposition of bands of the aponeurosis derived 
from the front of the bone, which favours ligamentous union 
even if they are kept close together. 

In order to fulfil these indications the hip is bent and the 
knee fully extended, so as to rehix the quadriceps. A back 
splint is applied, made, for instance, from poroplastic felt 
moulded to the part ; if necessary the effused blood is let out 
by puncture, the fragments are brought together, and the 
torn aponeurosis displaced as far as possible by rubbing them 
one on another. Bands of strapping fixed to the splint are 
made to press the fragments in apposition. Once or twice 
every day the quadriceps has massage, and less frequently 
the weak faradic current applied to it. When the patient 
is discharged he must continue for some months with 
the use of a leather knee-cap, whilst every day practising 
slight passive and active motion of the joint. Without doubt 



142 CHAPTER IV. 

tlie closer the fragments can be brought together^ and the 
more firmly they unite, the better as a rule will be the ultimate 
function. A patella united only by ligament, even though 
there is little separation, never gives the normal stability in 
the limb. For this reason many surgeons advocate operation 
as a primary measure of treatment. Many forms are em- 
ployed ; thus, for instance, two needles are passed transversely 
through the quadriceps and through the ligamentum patellpe, 
and approximated by silk threads, or a silver wire may be 
passed subcutaneously around both fragments in the vertical 
direction. Malgaigne's hooks are now hardly ever used. 
On the other hand, primary direct suture of the fragments, 
which involves opening the joint, finds more and more advo- 
cates, though it should be done only by skilled surgeons. I 
have myself carried this out when the simpler treatment 
with splint, massage, &c , had not led to the desired result, 
and with considerable success.^ As particularly unfavourable 

1 The question whether a recent! j fractured patella should be operated on 
or not is a most difficult one. Various methods of subcutaneous " suture " 
have been introduced, of which probably the best is that advocated by Mr. 
A. E. Barker, which consists in tying the two fragments together by 
aseptic silk ligature, which passes right round them in the vertical direc- 
tion, and is left permanently in. The ligature is introduced on a curved 
needle mounted on a handle, and rests against the articular cartilage and 
the subcutaneous surface of the bone. It may, however, be said that most 
surgeons, if they operate at all on fractured patellae, prefer to expose the 
line of fracture by an open incision, to thoroughly remove all blood-clot, to 
lift up and cut off the shreds of aponeurosis that almost invariably dip 
down between the fragments, and then secure the latter in firm apposition 
by one or two loops of stoi;t silver wire introduced by means of a drill, the 
wire being twisted up tightly, and its ends lightly hammered down level 
witli the surface of the bone. The wire should just avoid the articular 
cartilage, and by being introduced very obliquely should get a firm grip of 
each fragment. It remains permanently in place unless it later on cause 
irritation and require removal (which, it may be remarked, is no easy 
matter). If asepsis has been secured, and in no other operation are such 
elaborate precautions called for in disinfecting the skin, &c., the ultimate 
result is generally extremely good. The patient is able to bend the knee 
within a few weeks of the operation, he need wear no cumbrous knee-cap, 
the fracture unites by bone (though probably no bone forms callus with 
more slowness than the patella), and there is little risk of re-fracture. But 
owing to the unfortunate results which have occurred from time to time 
due to septic inoculation at the time of operation, and also to the very fair 
results which are seen from the non-operative treatment, wiring the frag- 



INTEA-ARTICÜLAE INJURIES TO THE KNEW-JOINT. 143 

complications of tlie fracture we may note complete absence 
of any union and coalescence of the upper fragment with the 
anterior surface of the femur^ a condition which is observed 
in old cases not very infrequently ; every attempt at flexion 
then naturally causes separation of the fragments, &c. 
Stretching of the ligamentous union and even re-fracture of 
the bone are not very uncommon. 

Other Infra- articular Injuries to the Knee-joint. 

A. Detachment of part of the articular cartilage from the 
femur (Plate LXIII, fig. i). — It is well known that the knee- 
joint is not a simple hinge one, and during flexion a fair 
amount of rotation of the leg together with ab- or adduction 
can be effected. During these movements the crucial liga- 
ments and the semilunar cartilages are of great importance. 
If when the knee is bent the bones are pressed together, 
with lateral twisting, a portion of cartilage, with the adja- 
cent spongy bone, may be forced off the end of the femur. 
The force which produces this is often surprisingly small, and 
may be, for instance, only an unexpected movement of the 
knee. The edges of the detached piece of cartilage are 
sharply cut, and its size may be that of a bean or almond. 

It is possible to produce this lesion by experiment on the 
dead subject. The detached portion may be completely 
loosened and form at once a foreign body in the joint ; pro- 
bably there are also cases in which it remains for a time still 
connected with the rest of the bone, and only forms a " loose 
cartilage " in process of time as a result of recurrent pres- 
sure and active movement ; the loose cartilage must naturally 
be removed by operation according to surgical rules. 

ments, so far from having become the routine practice, is apparently less in 
favour than it was a few years ago. Thus out of forty cases of recent 
fracture of the patella treated at one of the largest general hospitals in 
London last year, only two were operated on, though the result in these two 
left nothing to be desired. The surgeon who does perform the open opera- 
tion will, I think, be convinced that no other method is likely to obtain 
such complete apposition of the fragments and such firm union, but whether 
the risk of the operation is justified or not is still an open question. If 
wiring be decided on, a few days should always be allowed to elapse after the 
accident in order that the inflammatory reaction may subside, and the skin 
over the joint may be rendered thoroughly aseptic. — J. H. 



144 CHAPTER IV. 

B. Injur II to the, semilunar cartilages (Plate LX I II, fig. 2). 
— Under this heading come dislocation and rupture of the 
semilunar cai'tilages, which accidents may occur as indepen- 
dent injuries. 

In 1892 Bruns was able to collect forty-three cases. The 
internal semilunar cartilage is concerned twice as often as 
the external one ; usually the attachment of its anterior end 
is torn, but the cartilage is very rarely completely detached or 
divided in its continuity. In the production of this accident 
strong rotation of the lower end of the femur when the knee- 
joint is bent usually occurs, and it is exceptional for it to 
happen in a perfectly sound normal joint ; for this reason the 
injury is most frequently observed in England among foot- 
ball players and the like.^ 

Syinjjtoins vary in intensity, but there is always marked 
pain felt on pressure on the side of the joint concerned. 
'I "he latter is slightly flexed and cannot be fully extended, 
and there is effusion into it. 

In cases where the displacement has occurred over and 
over again, the pain and impaired mobility become lessened 
in degree. Objective examination frequently reveals a flat 
moveable body, which during extension projects at the fore 
part of the inter line and in flexion disappears. As it moves 
forwards and backwards a sort of snap may be felt by 
both surgeon and patient. When the detached end of 
the semilunar cartilage remains in the centre of the joint 
the inter line may simply be more hollowed and painful to 
pressure than normal, but if there is much effusion the 
diagnosis may be impossible, and it is generally very difficult, 
from the cases of loose cartilage (foreign body) . 

Treatment. — In recent cases reposition and moderate 
pressure, and later the use of ])laster-of- Paris bandage in 
extension, with subsequently the continued use of a light 
1 In violent ilexion ot the knee-joint tlie (-'orce exerted tlirongh one of 
tlie crucial li.L^ainents may tear off a piece of bone from either the tibia or 
tlie femur. In a remarkable case recorded by Mr. Erichsen a boy fell a 
considerable distance with both knees flexed. At the post-mortem it was 
found that on one side the anterior crucial ligament hod torn away part of 
the tibia, on the other side its attachment to the femur, i.e. pait of the 
externnl condyle. In such cases there is sure to be much effusion of blood 
into the knee-joint, with probably much impairment of mobility. — J, H. 



Tab. 63. 





HäXI-ÖOL^ 





Fig. 3b 




Fig.1 



üAg.k 



LithAisl.v. F. Reiolihöld , München 



PLATE LXIII. 

Fig. I. — Traumatic detachment of a fragment of bone and cartilage 
from the inner condyle of the femur. 

Fig. 2. — Rupture of the internal semilunar cartilage. 

Figs. 3 a and 3 b. — Fracture from compression of the upper end of 
the tibia due to a fall from a hay wagon, in which the femoral con- 
dyles and the tibia were driven together. The patient, a young 
woman, died of acute sepsis resulting from a spiral fracture of the 
same tibia in its lower part (see Langenbeck's ' Archives,' vol. xli, 

P- 357)- 

Fig. 4. — Fracture of the left tibia just below the head of the bone 
united with deformity ; it was due to direct violence. 



FRACTURE OP BONES OF LEG AT THKlll UPPER ENDS. 145 

knee-cap, should be employed. In old and recurrent cases 
the cartilage may be fixed by deep sutures, but this is a • 
somewhat dangerous proceeding, and the best course to 
adopt is the excision of the cartilage concerned, which seems 
to have but little effect on the subsequent use of the joint. 

Fracture of the Bones of the Leg at their Upper Ends. 

A. Fracture from compression of the tibia through its 
articular surface (Plate LXIII, fig. 3; Plate III, fig. i).— 
This fracture results from violent pressure of the tibia 
against one or other condyle of the femur j as, for instance, 
by a fall from a considerable height on to the feet. Cases 
have occurred in mountain climbing, in a fall from a wagon, 
and I have even known it result from jumping off a bicycle. 
There may be simply a fissure traversing the joint surface, or 
in bad cases the joint end of the tibia may be crushed into 
two or more fragments, between which the shaft is impacted. 
There will be first extravasation of blood into the joint, 
and later considerable synovitis ; movements of the joint are 
painful, and perhaps abnormal lateral mobility can be 
obtained. The upper end of the tibia may be increased in 
width, and is very painful to pressure. If the fracture 
involves only one half of the tibial surface there may be a 
tendency to varus or valgus, the former being most frequent 
owing to the inner tuberosity of the tibia being most often 
involved. There is considerable risk of arthritis deformans 
supervening. In the treatment weight extension should be 
employed, with, if necessary, lateral traction to correct the 
varus or valgus. 

Massage and passive motion of the knee-joint should be 
employed as soon as practicable. 

B. Fracture of the tihia below the tuberosities. — This 
form is rare, and results, as in the case shown in Plate 
LXIII, fig. 4, from direct violence, such as a kick, or 
more rarely from such an indirect force as might lead to a 
fracture of the lower end of the femur or a dislocation of the 
knee. The line of fracture may be quite oblique, and may 
enter the knee-joint, causing effusion into the latter. 

The diagnosis, which depends chiefly on the inci-eased 

10 



146 CHAPTER IV. 

widtli of the bone^ its tenderness on pressui-e^ and the 
abnormal mobility^ can only be made out under an ana3sthetic. 
The best treatment consists in weight extension, with the 
injured region left exj)osed, so as to render massage and com- 
pression by bandage possible. It may be necessary to correct 
the tendency to varus or valgus. 

C. Traumatic detachment of the itpper ejpi'physi.s of the tibia. 
— This injury is rare, but its possibility must be considered 
in any case of severe injury to the region of the knee-joint in 
a child. A correct diagnosis is only possible under an anses- 
thetic, when abnormal mobility and cartilaginous crepitation 
may be ascertained. 

D. Detachment of the anterior tuberosity of the tibia. — 
This is a very rare injury. It nearly always involves the 
knee-joint ; the fragment of bone which is drawn u^p wards by 
the quadriceps can be felt to be moveable in all directions, and 
active extension of the knee is impossible. The best treat- 
ment consists in fixing the fragment in place by a steel nail, 
with the joint in the extended position. 

Fracture of the Upper End of the Fibula. 

The head of the fibula may be broken off by direct violence 
(for example, by a kick or fall, or by a strong contraction of 
the biceps muscle). The external popliteal nerve may be 
damaged at the same time. The upper fragment is not 
always displaced, but should it be so, fixing it with silver 
wire will probably give the best result. 

Fracture of both Bones through their Shafts. 

This injury is very common, resulting usually from direct 
violence (being run over, &c.). In such cases both bones are 
probably involved about the same level. 

If from indirect force, and particularly from a violent 
twist of the leg with the foot fixed, the tibia will give way 
towards its lower end obliquely, whilst the fibula, being 
unable to support the weight of the body alone, bends and 
breaks at a higher level. Naturally the cases of oblique 
fracture are attended with more risk of overlapping and 



Tab. 64. 




Eig.^cu 





Fig.1 



Litli.A3st y. y ReichhoW . Miinchm 



PLATE LXIY. 

FRACTURES OF TIBIA AND FIBULA. 

Fig. I. — United fracture of both tibia and fibula at about the same 
level ; marked lateral displacement, with union of all four fragments 
together. 

Fig. 2. — Specimen of a united fracture of the lower third of the 
tibia and the upper third of the fibula . 

Fig. 3. — Guide to determining the correct position of the limb after 
fracture, showing that a line drawn from the anterior superior spine to 
the great toe passes through the patella at about its centre. 

Figs. 4 and 4 a. — Isolated fracture of the tibia in its upper third, 
with upward dislocation of the fibula. In the case i-epresented by 
fig. 4 there was shortening of 3 cm. 



FRAÜTÜUES Ob' 1U)TH BON ES THROUGH THKIB SHAFl'S. 147 

defective union than those of transverse fracture. The 
sharp lower end of the upper fragment is apt to project under 
the skin, and may perforate it. 

The diaijnods is usually easy, although the exact position 
at which the fibula breaks may be uncertain, unless the 
Röntgen rays are employed. Any degree of twisting of the 
lower fragment can be determined by following with the 
finger the exact line of the tibial crest. 

In examination for abnormal mobility an assistant should 
fix the knee joint Avith his hands, whilst the surgeon, placing 
one hand over the supposed site of fracture, grasps the foot 
with his other hand and moves it in the direction of ab- and 
adduction. If the diagnosis is still difficult, it may be ad- 
visable to rest the upper fragment firmly against some part of 
the surgeon's body — such as his thigh — whilst fixing it with 
the left hand, and then, with the right hand grasping the 
foot, to try for abnormal mobility. 

Treatment. — The tendency to overlap of the upper frag- 
ment (much more rarely of the lower fragment) can nearly 
always be overcome by direct traction and manipulation ; 
though if the fracture be oblique, displacement readily occurs. 

Grreat care must be exercised in order to obtain the best 
possible position of the fragments. With this object the 
relation of the foot and leg on the affected side to the hori- 
zontally placed patella should be compared with that present 
in the opposite limb. The statement that the anterior 
superior spine, the inner border of the patella, and the inner 
edge of the great toe lie in the normal subject in one straight 
line is not wholly true (see Plate LXIV, fig. 3) . In putting 
up the limb the knee must be extended and the foot placed 
at a right angle, and there is nothing better during the first 
week than back and side splints. At the end of this time I 
believe it is best in many cases to readjust the limb in well 
padded plaster-of-Paris splints, and sometimes an aneesthetic 
should be given for this. This proceeding should be re- 
peated after another eight days or so have elapsed, when an 
ordinary plaster-of-Paris bandage may be employed. 

Lateral deviation can in this manner be easily prevented, 
but it is more difficult to prevent a tendency to inward rota- 
tion of the lower fragment, especially if the fracture is 



148 CHAPTER IV. 

situated towards tlie upper end of tlie shaft. Care also 
must be taken lest some backward bending at the seat of 
fracture should occur (see Fig. 124). It will be readily 

Fig. 124. Fig. 125. 



/ 



- 



I^^JU^J^"'"""-"^:^..^: 




Fig. 124. — Fracture of the leg united with backward curve. 
Fig. 125. — Lateral bending of the leg after union of a fracture. 

understood how likely this is to happen when the plaster of 
Paris is applied early and the limb supported by the assist- 
ant's hands above and below the line of fracture. The use 
of weight extension^ elevation of the limb from the cradle with 
relaxation of the calf muscles by flexion of the knee^ will 
usually suflßce to correct any tendency to overlap of the ends 
of the bone. Is it advisable to apply plaster- of -Paris band- 
ages soon after the accident in a case of fracture of the 
tibia and fibula ? The answer to this question is that many 
surgeons have found this method of treatment more con- 
venient than any other. I would, however, refer the reader 
to some remarks on the subject in the early part of this 
book. The immediate application of plaster-of-Pa ris band 



AMBULATORY TKEATMKNT OF FRACTURES OF THE LKG. 149 

ages requires much technical skill and constant supervision, 
and in some cases considerable risk is run. The sooner the 
fracture is seen by the surgeon the safer it is to apply 
plaster-ofrParis bandages, whilst the swelling is but slight, 
and whilst an exact reposition can be secured ; whereas after 
one or two hours have elapsed there is greater difficulty or 
more risk. 

It may be said, finally, that it is only justifiable to employ 
the immediate application of plaster of Paris in these cases 
when the surgeon is experienced in its use and is able to 
supervise the patient from day to day. 

After union has taken place, baths or douches to the limb, 
with massage over the muscles and active and passive move- 
ments of the adjacent joints, may be employed. If a con- 
spicuous or painful projection of bone remains at the site of 
fracture, it should be removed with the chisel after the bone 
has been exposed by turning up a small flap. 

The prognosis of this form of fracture depends almost en- 
tirely on the treatment. If this is properly carried out and 
there are no complications, complete restoration of function 
should occur. Experience, however, shows that this result 
is not obtained at the present day in 50 per cent, of the 
cases, since deformity at the site of fracture, oedema of the 
leg, stiffness of the adjacent joints, &c., frequently result and 
impair the capacity for work during long periods of time or 
even permanently. 

The Ambulatory Treatment of Fractures of the Leg. 

In the course of the last few years attempts have been 
revived to treat cases of fracture of the tibia and fibula with 
some apparatus that will allow of the patient getting about 
during the whole progress of the treatment. Some modifi- 
cation, for instance, of Thomas's splint, by which elastic ex- 
tension is provided to the foot and the patient bears the 
weight of his limb on the tuber ischii, is suitable for this 
method. Some recommend plaster-of-Paris bandages or 
splints which only immobilise the leg and foot whilst leaving 
the knee-joint free. In any case the apparatus must be 
applied when all displacement is completely overcome, and it 



150 



OHAPTKIf. IV. 



must be strong enough to prevent its recurrence whilst the 
patient moves about. It is wise to renew the apparatus 




Fi<?. 125A. — Old unnnited fracture of tibia with compensatory 
hypertrophy of tlie fibula, which had become abnormally curved 
outwards owing to the weight transmitted tlirough it. The 
patient had been able to walk. Ti'om Sir Astley Cooper. 

once or twice. I am still of opinion that the ambulatory 
treatment is not suited for general practice^ although it 
may now and then give satisfactory results. 

A. Fracture of the tibial shaft aluve (Plate LXIV^, figs. 4 
and 4 a). — It has been already noted that fracture of both 
bones of the leg is often in the first instance of the tibia 
alone, the fibula giving way secondarily. The same thing 



Tab. 65. 




Eig.1 






Eig.2 



Eig.3 





Etgi^a^ 



Fig.kb 



litlilnsl.v. F. Reichhöld, Münchm 



PLATE LXV. 

FBACTUKES OF TIBIA AND FIBULA. 

rig. I. — Longitudinal or spiral fracture dvie to torsion of tlie lower 
third of the tibia. From the same case as that represented in figs. 3 a 
and 3 b, Plate LXIII. It will be noted that the fracture extends into 
the ankle-joint. 

Fig. 2. — Fractures from torsion of the lower part of the tibia. 

Fig. 3.— Badly united fracture in lower third of both bones, witb 
displacement of the foot in the direction of pes valgus. 

Figs. 4 a and 4 b. — Fracture above the malleoli united with] marked 
deformity (pes varus). A normal leg is shown for comparison. 



ARIBÜLATOKy Tli'EATMKNT OF FK'ACTUllKS OF THK f/KG. löl 

may happen during osteoclasis^ from torsion, and from forced 
bending of tlie leg. 

Fracture of the tibia alone may result from direct and 
indirect violence, and if it be oblique the diagnosis may be 
easy owing to projection of one fragment, even although the 
fibula is intact and acts as a splint. The diagnosis is diffi- 
cult if the fracture be transverse ; in the want of other 
symptoms, a kind of cracking or snapping sound with forced 
movements, together with pain on pressure and percussion, 
may be useful. Very marked deformity at the site of the 
tibial fracture is always accompanied either by fracture or 
dislocation of the fibula. In the treatment a perfect reduction 
and retention in good position is more readily obtained than 
in the case of fracture of both bones, and plaster of Paris or 
the " ambulatory treatment " may be used with less risk. 

13. Fracture ot the lower end of the tihin and fibula. — These 
fractures are generally the result of forcible lateral movement 
of the foot, either outwards or inwards, complicated some- 
times by a twisting or rotation of the foot. Fracture just 
above the malleoli deserves special notice, since it resembles 
the supra-condylar fractures at the lower end of the hume- 
rus, and also from the marked tendency to union with 
deformity, such as is shown in Plate LXV, figs. 3 and 4. 
Besides the curvature here illustrated, the lower fragment 
may be displaced backwards. Since marked deformity is 
usually present from the first, the diagnosis is easy. 





?^ 


• ' \\> 


r - - - 


.;*■- ^^ 


S^ .'-1 




^^^^-' " ' 








IR\ 










^ . /-t 



Fig. 126. — Extension and counter-extension applied to the leg with 
pressure exerted on the upper fragment by means of a weight. 



152 CHAPTER IV. 

In putting np tlie fracture the surgeon must guard against 
over-correction^ • and especially against the tendency of the 
foot to be displaced backwards. 

In old cases which have united with marked deformity 
and disturbance of function^ the only thing that can be done 
is osteoclasis or osteotomy. 

Putt's fracture (see Plates LXYI and LXVII) . — As is well 
known^ this may result from violent inversion or more 
commonly eversion of the foot. Both methods can be 
illustrated on the dead subject, and it is hardly necessary to 
go into details on the diagnosis of this very frequent and well- 
known injury. It involves, of course, opening the joint, and 
is doubly important since this joint has to bear the whole 
weight of the body. We see even at the present time great 
errors made sometimes in the treatment, errors which cripple 
the capacity for work of the patient for his whole life. 

The anatomical conditions involved in this fracture are 
worthy of special note. The fragment broken off the inner 
malleolus is sometimes quite small. The inward bend of the 
fibula leading to its fracture is hardly possible without a 
tear of some of the strong ligamentous bands passing between 
the two bones at their lower end.' A small part of the tibia or 
fibula surface may be torn off as shown in Plate LXVI, 

^ Dupuytren' s Fracture. 
A rave hut interesting variety of fracture at the ankle-joint is that first 
descrihed bj Dupuytren, in which togetlier with detachment of the internal 
malleolus and fracture of the fibula about three inches up, the astragalus 
acting as a wedge forces apart the lower ends of the two leg bones. In 
order that this should occur the very strong inferior tibio-fibular ligaments 
must be torn or the adjacent outer edge of the tibia prized off. So much 
force is required to do this that this complication occurs not more often 
than once in loo cases of Pott's fracture. Three specimens exist of it; 
one (figured by Sir Astley Cooper) in St. Thomas's Hospital Museum, a 
second by Mr. Thomson (" Brit. Med. Journ.' for 1880, vol. i, p. 919), and a 
third wliicli I placed in the London Hospital Museum (see ' Path. Trans.,' 
1888, p. 238). Tiie remarkable ascent of the astragalus between the tibia 
and fibula and the consequent widening of the ankle make this form of 
fracture noteworthy, and although the displacement may be reduced by 
traction the ultimate result is not likely to be so good as that of an ordinary 
weli-lieated Pott's fracture. In several cases it is stated tliatthe impaction 
of the astragalus could not be reduced, and the utility of the leg was con- 
sequently much ini))iiired. — J. H. 



Tab. 66. 





Eu/.i 



Fig. 2 



Lith Als! .\', F. ReinWiold . Münchm . 



PLATE LXYI. 

TYPICAL pott's FRACTURE. 

The detachment of the internal malleolus and the fracture of the 
fibula a short distance above the ankle are seen in both specimens, 
which were obtained by experiment on the dead subject. The valgus 
deformity is also well shown. 

In fig. I some separation of the lower ends of the tibia and fibula is 
seen. 



Tab. 67. 




•■^- i'Äg.i 




Eig.2cL 




Eig.2b 




Llthinsi.v. F Reioliholfl , Müilchm 



PLATE LXVII. 

FRACTURES ABOUT THE ANKLE-JOINT. 

Fig. I. — Normal epiphysial lines at the lower end of the tibia and 
fibula. 

Figs. 2 a and 2 h. — Pott's fracture united with deformity (marked 
flat-foot), 

Figs. 3 a and 3 h. — Pott's fracture with backward displacement of the 
foot. 



AMBULATORY TREATMENT OP PEACTrURES OP THE I, EG. 153 

fig. I. It is clinically of importance to remember that some 
cases of Pottos fracture may be able to walk, tliongli with a 
limp, shortly after the accident. 




Figs. 127 and 128. ^Compound Pott's fracture in a woman aged 
forty-five. After enlarging tlie wound the fragments were 
replaced, and under antiseptic treatment a good ret^ult was 
obtained. 

Treatment.— -It is all-important to obtain an exact re- 
position. It used formerly to be advised that the eversion 
of the foot should be over-corrected ; in other words, a splint 
applied with the ankle strongly inverted. This, however, is 
not necessary, provided the eversion is overcome as well as 
the tendency to backward displacement. When effecting 
this the angular depression opposite the fractured fibula (see 
Plates LXVI and LXVII) disappears when the surgeon 
presses the two lateral surfaces of the ankle together. In a 
very complicated case I was obliged to fix the lower end of 
the fibula to that of the tibia with a peg. It is of great im- 
portance to place the foot at right angles to the leg, and 
otherwise in correct position. In the first few days wooden 
splints are best applied, then plaster-of-Paris bandage or 
lateral splints. During the first fortnight the apparatus 



154 



CHAPTKIt TV. 



should be taken down every three or four days, so that the 
ankle may have massage and passive movement used to it, 
and also in order that the correct position of the ankle may 
be observed, for I have known in a case of Pott's fracture 
an excellent position obtained at first, and then spoilt by 
want of attention to the splints. Much later, when the 
fracture has united, it is advisable that the patient should 
wear a boot that is strengthened at the side by steel, so as 
to prevent the tendency to valgus. 

Dupuytren's splint applied as shown in Fig. 129 is well 
adapted to correct this eversion of the foot. 
It will be seen in the illustration that the 
splint is applied on the inner side of the 
leg, and that the pad does not reach to 
the ankle-joint, so that the foot can be 
drawn towards the splint by turns of 
bandage. If the surgeon has to treat a 
case of this fracture which has united in 
bad position, it may be necessary to per- 
form osteotomy of the fibula, and fre- 
.quently also of the internal malleolus, in 
order to get the foot into good position. 
I have succeeded in several instances 
after doing osteotomy of the fibula at the 
old site of fracture in straightening the 
foot with Eizzoli's osteoclast ; the after treatment must be 
the same as for a recent fracture.^ 

c. Fracture of both vialleoli. — If forcible adduction of 
the foot has torn off the external malleolus, it is possible 

V The best operation to perform in these cases is not yet quite certain. 
A priori osteotomy of the fibula with foicible straightening of the ankle as 
described by the author might be expected to suffice, but whether it is from 
changes about the inferior tibio-fibular joint, or from overgrowth of bone 
about the internal malleolus, the fact is that this operation may almost 
entirely fail. On the other hand, an osteotomy above the ankle-joint 
through both tibia and fibula (one incision only being needed) gives on the 
whole better results, and has the advantage of not involving the ankle- 
joint. If necessary a thin wedge of the tibia should be removed. The 
eversion of the foot must be completely overcome, slight backward dis- 
placement is of comparatively little importance, and it is probably never 
worth while to operate for this alone. — .1. H. 




Fig. 129. — Dupuy- 
tren's s))lint applied 
to Pott's fracture. 



THE FOOT. 155 

that the foot may be driven against the internal malleolus 
and break that also. This injury is^ however, yevj un- 
common, and we need only allude to it here together 
with other rare forms, such as a vertical fracture through 
the tibia caused by violent twisting of the foot. Careful 
examination will enable a satisfactory diagnosis to be made 
in most of these cases, and the treatment does not differ 
from that required in other forms of fracture above the 
ankle. 

D. Separation of tJie lower epiphysis of the tibia (see 
Plate LXVII, fig. i ) . — This is a rare accident, which can 
naturally only happen to young subjects. It has been 
several times observed during forcible rectification of bad 
cases of club-foot. Abnormal mobility and cartilaginous 
crepitus are the chief signs of its occurrence. 

The lower end of the tibia or fibula may alone be fractured 
by moderately severe indirect or direct violence, and the dia- 
gnosis may offer some difficulty. Pain on pressure or on ab- 
er adduction of the foot are perhaps the chief signs, and 
doubtful cases should be treated as though there were a 
fracture, after the method already described. 

The Foot. 

The movements of the foot, as is well known, take place, 
so far as flexion and extension are concerned, mainly at the 
ankle ; as regards inversion and eversion, chiefly in the joints 
between the astragalus and the other bones. 

Jt is obvious that exaggeration of these motions may lead 
to dislocation in the respective joints. 

A. Dislocation at the ankle-joint (see Plate LXVIII). — 
As shown in the illustration, the foot may be dislocated 
either forwards or backwards ; its position is so characteristic 
that no difficulty can be experienced in making the diagnosis, 
and reduction may be effected by direct pressure on the tibia, 
together with bending of the foot in the direction in which 
the dislocation was produced. A coincident fracture of one 
or other malleolus is without much importance. A pure 
lateral dislocation without fracture is impossible. 

p.. Suhafitraijalar dislocation, may occur either in the 



156 CHAPTKK IV. 

inward direction from forced in\^ersion^ or outward from 
aversion of tlie foot. The diagnosis may oifer considerable 
difficulty. In any doubtful case an ansestlietic should be 
giveuj and the latter aid^ with full relaxation of the muscles^ 
is necessary in order to effect reduction by appropriate trac- 
tion and direct pressure. 

c. Dislocation of the astragalus alone. — This may occur in 
several directions. The mechanism of its production is com- 
plicated, and not at present fully understood. The diagnosis 
is fairly easy owing to the projection of the astragalus under 
the skin and the approximation of the tibia to the other tarsal 
bones, i. e. it may articulate directly with the os calcis. 
Reduction is difficult, and in any case where other methods 
fail, both in dislocation of the astragalus and the subastra- 
galar form, the surgeon should operate. It is noteworthy 
that aseptic incision, &c., has given good results, although the 
astragalus may have had its vascular and ligamentous connec- 
tions seriously damaged.-^ 

Fracture of the astragalus is extremely rarely an injury 
confined to this bone. Thus, for instance, in severe cases of 
fracture of the os calcis the astragalus may give way, especi- 

' Although the distinction between subastragaloid dislocation and that 
of the astragalus itself is a clear one, it sometimes happens that the foot is 
displaced (generally inwards) from the astragalus, whilst the latter bone is 
also partially displaced at its upper articulation. Of this mixed form there 
is a specimen in the London Hospital Museum. There is yet another 
variety, in which with a subastragaloid dislocation the neck or other part 
of the astragalus itself is fractured. Sir William MacCormac narrates a case 
of this in a paper in ' St. Thomas's Hospital Reports ' (see also Pollock, ' Med.- 
Chir. Trans.,' vol. xliii ; and Broca, Soc. de Chir., i860). M. Broca collected 
seventy-eight cases of simple dislocation of the astragalus and eighty cases of 
compound dislocation. In the great majority of tliese reduction was impos- 
sible, and the astragalus had to be excised. Out of eighty-six operations 
primary excision of the bone was performed fifty-nine times with seventeen 
deaths, secondary excision twenty-seven times without a death. According to 
Sir William MacCormac it is important to aim at ankylosis between the tibia 
and the os calcis, lest tlie foot should be too weak. There is no doubt that 
many cases recorded as dislocation of the astragalus have really been examples 
of subastragaloid dislocation. In cases of either, where, under thorough 
anaesthesia and relaxation of the calf muscles by flexion of the knee, reduction 
still cannot be effected, the tendo Acliillis should be divided. The tibialis 
posticus may also be a serious obstacle to reduction, and may also require 
division. — J. H. 



Tab. 68. 




mg.1 




Fig. 2 



Lükänst.v. F. Reiolihöld, München 



PLATE LXVIII. 

DISLOCATIONS Al THE ANKLE-JOINT. 

Figs. I and i a. — Backward displacement of the foot, the peroneal 
tendons being placed between the astragalus and the external malleolus, 
and the foot apparently shortened whilst the heel projects abnormally. 

Figs. 2 and 2 a. — For\/ard dislocation of the foot, the front part 
appearing to be lengthened whilst the heel does not project to the 
normal extent. 



THE FOOT. 



157 



ally at its neck, and parts of this bone may be detached or 
bent in by the same force that leads to a dislocation at the 
ankle-joint. The diagnosis may offer considerable difficulty, 
the chief points to be noticed being alteration in the shape 
of the foot, abnormal projection at its dorsum, pain on pres- 
sure over the neck and head of the bone, filling up of the 
" sinus tarsi," limitation of movement, especially in dorsal 
flexion. Measurement with the callipers may also show 
differences on comparison with the sound foot. 

Fracture of the os calcii^. — One has to distinguish between 
fracture of the body of the bone and that of its processes, 
the latter including the projection of the heel and the susten- 
taculum tali. Fracture from compression of the bone (see Fig. 
130) results from a fall upon the foot, or from alighting 




Fig. 130.— Comminuted fracture from compression of the os calcis, 
produced artificially. 

awkwardly when jumping. It has hence been chiefly met 
with amongst house painters, masons, mountain climbers, 
&c. The OS calcis is crushed between the ground and the 
astragalus, and besides a longitudinal fracture there may be 
numerous other fissures in the bone, which may, indeed, be 
quite comminuted. In such severe cases the symptoms are 
characteristic. The os calcis is widened, flattened, and 
painful ; the malleoli, especially the inner one, are approxi- 
mated to the ground, and an appearance of flat-foot is given 
(see Fig. 131). Mobility of the ankle-joint may be unaffected ; 
on the other hand, the inversion and eversion movements are 
certain to be impaired. Sometimes the fracture occurs in 
both feet. The diagnosis is more easy in old cases than in 
recent ones, on account of the formation of callus and secon- 
dary changes. Cases of it are much more common than was 
formerly thought, since they were readily mistaken for those 



158 CHAPTER IV. 

of severe sprains. The diagnosis demands careful examina- 
tion, and we may note amongst the symptoms which are 
sooner or later observed — 

1. Increase of width of the heel (up to 2 cm.). 

2. Filling up of the normal hollows on either side of the 
tendo A chillis from oedema. 

3. Atrophy of the calf muscles. 

4. Marked impairment in walking power. 

5. Persistent tenderness of the foot. 

6. Abnormal contour, especially depression of the malleoli. 
The prognosis of this fracture is not very favourable, even 

if it be recognised early ; the function of the foot may be 
permanently damaged, and this is the more likely to occur 
since recent observations have shown that neighbouring bones 
(the astragalus and malleoli) are not infrequently implicated 
at the same time. In the treatment, when it is possible, the 
fragments should be got into position and fixed there for a 
long period in order to avoid flat-foot supervening. In the 
early stages it is dangerous to employ much compression for 
fear of fat embolism ; at a later stage compression and 
massage with passive motion, &c., should be thoroughly em- 
ployed. 

Fig. 131. Fig. 132. 



n't: 




Fig. 131.— CoTinninuted friicture of the left os calcis resulting 
from a fall on the foot. 

Fi«,'. 132.— Fiacture of the os calcis with upward displacement 
of the heel fra(,nuent. The sketch was made four weeks after the 
injury. A subsequent operation resulted in <^ood union. 



DISLOCATIONS OF TH K FOOT. 159 

The projecting part of tlie os calcis forming the heel may- 
be detached by a sudden pull of the calf muscles^ may be 
broken off by direct violence^ or as part of a complicated 
fracture of the Avhole bone. The fragment will be drawn 
upwards by the calf muscles. It may be replaced when the 
knee is fully bent, and should be fixed in position with the 
aid of steel needles. The limb is then put up with the knee 
flexed and the foot hyper-extended. Under certain circum- 
stances it might even be advisable to divide the tendo 
Achillis obliquely, and suture it again so as to elongate the 
tendon and enable the fragment of bone to be secured to 
the rest of the os calcis. 

Fracture of the sustentaculum tali. — By this is meant a 
breaking off of the process of bone on the inner side of the 
OS calcis, which helps to support the astragalus and is 
grooved by the flexor longus hallucis. If it is fractured we 
find marked pain on pressure, the astragalus is depressed 
doAvnwards and inwards, the foot is in a position of valgus, 
and the movements of ab- and adduction of the foot are 
much impaired. In old cases we find bony thickening below 
the internal malleolus — due, as has been proved by dissection, 
to the detached fragment uniting with the astragalus. 

Isolated fracture of the sustentaculum is rare. It may 
occur during a slip in descending a stair, in a fall from a horse, 
or in jumping. More commonly it happens as a complica- 
tion of fracture of the internal malleolus, or of the rest of 
the OS calcis. 

Isolated fractures of the remaining tarsal bones are ex- 
tremely uncommon. Those of the metatarsus and phalanges 
have no great practical importance, and are easy both to 
diagnose and treat. 

Dislocations of the Foot. 

The distal row of tarsal bones are but rarely dislocated, 
but one or other may be partially or completely displaced. 
This condition may be recognised by careful palpation 
after the swelling of the foot has gone down under the in- 
fluence of massage, &c. Reduction may be very difficult, 
nnd an operation either to replace and fix with suture the 
displaced bone, or to excise it, may be indicated. 



160 CHAPTER IV. 

Dislocation of the metatarsal bones occurs particularly in 
the form of an upward displacement of all or nearly all the 
metatarsals at their tarsal articulation.' There is, of course, 
abnormal bony projection on the dorsum with hollowing of 
the plantar surface. Reduction is difficult, and in old cases 
can only be effected by operation. 

Dislocation of the phaln.ngef!, analogous to those of the 
fingers, is occasionally met with, due to forced hyper-exten- 
sion. The diagnosis is easy, and reduction is effected in the 
same manner as in the case of the fingers. 

^ An interesting example of this dislocation, that of all the metatarsal 
bones upwards and outwards at their bases, was under mj observation two 
years ago. Tiie patient, a man aged twenty-three, had fallen with his 
horse, the weight of the latter coming largely on the right foot. There 
was such excessive swelling of the whole foot for a considerable time that 
the dislocation was not detected. When this swelling had gone down and 
I saw the foot at the end of two months, the following condition was 
present : 

1. The internal cuneiform bone projected strongly downwards and in- 
wards when compared with the first metatarsal. 

2. There was a ridge along the whole dorsum of the foot corresponding 
to the tarso- metatarsal joint, and the foot was broader at its centre than on 
the other side. 

3. The second metatarsal was abnormally mobile at its proximal end (it 
will be remembered that it is fixed rigidly between the three cuneiforms). 

4. The base of the fifth metatarsal bone was displaced outwards, and half 
an inch nearer the external malleolus than on the other side. The foot was 
not greatly deformed, and the man was beginning to walk fairly well, but 
at the same time some impairment would probably always persist. The 
condition did not seem quite to justify an operation, without which any 
attempt at reduction would be quite useless. Remembering how firmly the 
second metatarsal is fixed in its place, probably with greater security than 
any other long bone in the body, a true dislocation of it with the other 
metatarsal bones such as has just been instanced, might seem incredible. — 
J. H. 



INDEX. 



Astrsigalus, fracture of . 
Axillary vessels^ injui'y to, iu re 

duction of dislocation . 
Base of skull, fractures of 

sym 
ptoms of 
Callus, excessive, simulating 
tumour . 
„ formation 
Clavicle, fractures of 

„ „ treatment of 

Colles's fracture of radius 
Compression of brain 
„ fractures 

Concussion of brain 
Delayed union 
Delirium tremens 
Depressed fracture of skull 
Dislocation of astragalus 
„ of clavicle . 

„ of foot 

„ of metatarsus 

„ of shoulder . 

,j „ diagnosis 

„ „ recurring 

„ „ treatment 

„ „ unreduced 

„ of vertebra . 

„ subastragalar 

Dislocations 
Dupuytren's fracture 
Elbow, dislocations of 

„ sprain in young children, 
pathology of . 
Elbo'.v-joiut, injuries to . 



PAGE 
156 

66 

27 

29 

54 
10 
51 
52 
97 
31 
5 
31 
13 
15 
25 

156 
56 

159 

160 
58 
62 
65 
63 
65 
47 

155 
22 

152 



92 
86 



Epiphysis, head of femur, separa- 
tion of . . 123 
,, lower, of femur, separa- 
tion of . . 133 
„ lower, of radius, separa- 
tion of . . 103 
„ lower, of tibia, separa- 
tion of . . 155 
„ upper, of humerus, 

separation of . 73 

Facial bones, fractures of . 34 

False joint after fracture . 14 

Fat embolism . . .11 

Faulty union . . 14, 21 

Femur, head of, fractures . 121 

„ lower end, fractures of . 131 
Forearm bones, fracture of . 92 

General symptoms of fractures . 6 

,, treatment of fractures . 18 
Greenstick fractures . . 3 

Hernia cerebri . . .26 

Hip, dislocations of . . 114 

Humeral shaft, fractures of . 77 
Humerus, fractures of lower end 

of . . .79 

„ fracture of neck . 69 

„ tuberosities, fracture of 69 
Hyoid bone, fractures of . 39 

Ilium, fractures of . .111 

Jaw, lower, dislocation of . 37 

„ fractures of . 35 

Knee, dislocations of . . 137 

Knee-joint, injuries to . 134, 143 

Meningeal hsBmorrhage with frac- 
ture of skull . . .31 

11 



162 



INDEX. 





PAGE 




PAÖE 


Meningocele, traumatic, in cliildr 


en 34 


Spinal cord, crushing of . 


42 


Nerve-trunks, injury to . 


12 


,, injuries, treatment of 


43 


Olecranon, fracture of . 


94 


Spine, fractures of 


40 


Optic neuritis from fractured 




Spiral fractures . 


132 


skull . . . . 


30 


Spontaneous fractures . 


1 


Os calcis, fracture of 


157 


Sternum, fractures of 


50 


Patella, dislocations of . 


137 


Subcoracoid dislocations. 


60 


,, fractures of 


188 


Sustentaculum tali 


159 


Plaster-of-Paris splints . 


19 


Thrombosis with fracture 


12 


Pott's fracture , 


152 


Thumb, dislocation of 


105 


Process of union , 


9 


Thyroid cartilage, fractures of 


40 


Prognosis in cases of fracture 


17 


Tibia, head of, fracture . 


145 


Radius, fractures of 


96 


„ and fibula, fractures of 


147 


Ribs, fractures of 


49 


Torsion fractures 


4, 132 


Sabre wounds of skull . 


b3 


Trephining the spine 


45 


Scapula, fractures of 


57 


Ulna, fractures of 


. 95 


Semilunar cartilages, displace 




Vault of skull, fractures of 


24 


ment of 


144 


Young children, dislocations 


Sinuses of skull in relation tc 




in . 


. 23 


fractures 


25 







riilNTED BT ADLABD AND SON, 
IJAKTHOLOMEW CLOSE, E.G., AND 20, HANOVER SQUARE, W. 



COUNTWAY LIBRARY OF MEDICINE 



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H36 E3 
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